216801868-2-3-2023-21-AS-CFES-CNPUF4-20230203143209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:32:23 PM

Document Has Been Signed on 02/03/2023 02:32 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:	DATE:	02/03/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Executive Director, Angela Boucher-Turin		TIME COMPLETED:	02:45 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 12:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director, Angela Boucher-Turin. The purpose of the visit was to follow up on three self reported incidents submitted to Community Care Licensing (CCL). LPA and Executive Director discussed the following reports: Incident Report 1: CCL received an incident report on 12/15/2022. Incident report states that on 12/12/2022 Resident 1 (R1) was observed on the floor by care staff. R1 obtained a large laceration to their right leg. Facility contacted Emergency Personnel to evaluate and resident was taken to the hospital. Facility made all appropriate notifications per regulation. On 12/15/2022, LPA and Executive Director discussed R1's plan of care upon their return to facility. As of 2/3/2023, R1 has been observed to be doing well. Incident Report 2: CCL received an incident report on 11/15/2022. Incident report states that on 11/4/2022, Resident 2 (R2) was observed to be hallucinating and had high blood pressure. Facility contacted Emergency Personnel to evaluate and R2 was taken to the hospital. R2 was diagnosed with pneumonia and sepsis. R2 was sent to a Skilled Nursing Facility. Facility made all appropriate notifications per regulation. LPA and Executive Director discussed R2. Per conversation, R2 did not present with any symptoms related to sepsis prior to being sent out to the hospital. As of 2/3/2023, R2 has made arrangements to move out due to changing care needs. 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: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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: 02/03/2023

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Continued from LIC-809

Incident Report 3: CCL received an incident report on 1/23/2023. Incident report states that on 1/21/2023, Resident 3 (R3) was observed on the floor by care staff. Resident stated they had been drinking that day and denied having pain or injuries. Resident was later found on the floor again by care staff with an empty bottle of alcohol. Facility contacted Emergency Personnel to evaluate and R3 was sent to the hospital. Facility made all appropriate notifications per regulation.

LPA and Executive Director discussed R3. As of 2/3/2023, Facility has been in contact with R3's Physician and Responsible Party regarding R3 and their care needs. Facility is monitoring R3 appropriately.

LPA conducted a walkthrough of the facility with Executive Director and discussed the following:

Covid and Influenza A Protocols
Staffing
Incident Reports
Training
Annual Inspections

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC 811 (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: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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