216801868-10-31-2022-21-AS-CFES-CKQVNR-20221031163535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 10/31/2022
Date Signed: 10/31/2022 04:35:56 PM

Document Has Been Signed on 10/31/2022 04:35 PM - It Cannot Be Edited

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 RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR:	ANGELA BOUCHER-TURIN		FACILITY TYPE:	740
ADDRESS:	515 NORTHGATE DRIVE		TELEPHONE:	(415) 491-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	160	CENSUS: 136	DATE:	10/31/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator/Executive Director, Angie Boucher-Turin, and Resident Care Director, Beki Darrow		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 12:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case-Management Incident visit and met with Administrator/Executive Director, Angie Boucher-Turin, and Resident Care Director (RCD), Beki Darrow. The purpose of this visit is to follow up on multiple self-reported incident reports submitted to Community Care Licensing (CCL) by this facility. LPA, Administrator, and RCD discussed the following reports: Incident Report 1: Incident Report was received by CCL on 10/3/2022. Report states that on 9/30/2022, Resident 1 (R1) was found on the floor by care staff and could not remember if they hit their head. Facility called 911 and R1 refused to go to the hospital. Facility made all appropriate notifications per regulation. Per conversation with Administrator and RCD, R1 is in Assisted Living and does not have a history of falling. R1 has been monitored since the incident and has been observed to be doing well. Incident Report 2: Incident Report was received by CCL on 10/3/2022. Report states that on 9/30/2022, Resident 2 (R2) was heard screaming for help by care staff. R2 was found on the floor and could not recall how they fell. Upon observation, R2 was found to have a bump on the back of their head. Facility called 911 and R2 was transported to the hospital. Facility made all appropriate notifications per regulation. Per conversation with Administrator and RCD, R2 is in Assisted Living and does not have a history of falling. R2 has been monitored since returning to the community and has been observed to be doing well. Incident Report 3: Incident Report was received by CCL on 10/5/2022. Report states that on 10/4/2022, care staff responded to Resident 3's (R3) pendant call. R3 was found face down on the floor and stated that their legs gave way while walking. R3 obtained a skin tear which was assessed and dressed by the facility nurse. Facility made all appropriate notifications per regulation. Continued on LIC-809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: 10/31/2022

NARRATIVE

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Continued from LIC-809

Per conversation with Administrator and RCD, R3 has a prior injury that is causing a loss of mobility now that they are older. R3 has an appointment scheduled with their physician to be seen.

Incident Report 4/Death Report: Incident Report was received by CCL on 10/17/2022. Report states that on 10/13/2022, care staff responded to Resident 4's (R4) pendant call. R4 was observed to be weak and pale. Facility called 911 and R4 was transported to the hospital. Facility made all appropriate notifications per regulation. Death Report was received by CCL on 10/17/2022 and occurred on 10/16/2022.
Per conversation with Administrator and RCD, R4 was aspirating when found by care staff. R4 did not have a history of aspiration and did not have any noted changes in condition or swallowing needs. Prior to incident, R4 did not mention any symptoms related to aspiration or feeling sick.

Incident Report 5: Incident Report was received by CCL on 10/25/2022. Report states that on 10/21/2022, Facility was notified by Sutter Home Health that Resident 5 (R5) had a change in condition regarding their wound. Facility notified R5's Physician and a visit was scheduled. R5 was transferred to a Skilled Nursing Facility the next day. Facility made all appropriate notifications per regulation.
Per conversation with Administrator and RCD, R5 is doing well, and their wound has been observed to be healing nicely.

Incident Report 6/SOC-341: Incident Report and SOC-341 was received by CCL on 10/24/2022. Report states that on 10/22/2022, Resident 6 (R6), reported to care staff that their jewelry was missing and stated that they took their jewelry off or may have thrown it away. Report states that R6's room and bathroom pipes were checked. Facility retraced R6's steps and also searched the garbage bags. Facility made all appropriate notifications per regulation.
Per conversation with Administrator and RCD, Facility conducted an internal investigation, but jewelry in question has not been located. R6 stated that they lost the jewelry and it was not facility's fault that it was lost.

Continued on LIC-809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

LIC809 (FAS) - (06/04)

Page: 2 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: 10/31/2022

NARRATIVE

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Continued from LIC-809C

Incident Report 7/SOC-341: Incident Report and SOC-341 was received by CCL on 10/24/2022. Report states that on 10/24/2022, Resident 7 (R7), reported to the RCD that they were missing two sheets of medication from their room. Administrator and RCD thoroughly searched R7's room for the medication. Facility made all appropriate notifications per regulation.
Per conversation with Administrator and RCD, Facility conducted an internal investigation and are in the process of reviewing video surveillance. Medication in question has not been located.

LPA conducted a walk-through of facility with RCD, Beki Darrow. Administrator/Executive Director, Angie Boucher-Turin was unavailable during the last half of the visit and gave permission for RCD to sign licensing documents in their absence.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

LIC809 (FAS) - (06/04)

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