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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 02/11/2022
Date Signed: 02/11/2022 12:02:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ALMAVIA OF SAN RAFAELFACILITY NUMBER:
216801868
ADMINISTRATOR:ANGELA BOUCHER-TURINFACILITY TYPE:
740
ADDRESS:515 NORTHGATE DRIVETELEPHONE:
(415) 491-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:160CENSUS: 112DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Administrator, Angela Boucher-TourinTIME COMPLETED:
12:15 PM
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License Program Analyst (LPA) Farhaan Sarangi arrived unannounced to conduct an Required – 1 year inspection of the facility. LPA was welcomed by front desk staff and was granted access into the facility. Administrator, Angela Boucher-Tourin arrived two minutes later.

LPA toured the facility on February 11, 2022 with Maintenance Manager, Brian Abshire and Administrator, Angela Boucher-Tourin. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on February 2022 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Fire drill, Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 01/31/2022. Last Disaster drill was conducted on 01/29/2022. Elevator was last inspected on February 10, 2022. Carbon monoxide detectors are hard wired with smoke detectors as well. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured at 115 degrees, within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 20 resident’s bathrooms while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Menus are available. There are special provisions made for individuals with special dietary needs. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A sample tour of resident’s bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. Resident’s at this facility are very independent and decorate their own apartments. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ALMAVIA OF SAN RAFAEL
FACILITY NUMBER: 216801868
VISIT DATE: 02/11/2022
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Residents specific special needs is posted on the wall in the kitchen area. Food is available for residents any time of the day. There is a daily activity schedule for residents. Medications were centrally stored in a double locked door. Medication cart in the facility medication room at the facility was also locked. Toxins are stored in a locked housekeeping room.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage. Facility was N95 Fit tested on December 2021.

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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