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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:10:01 PM

Document Has Been Signed on 01/15/2025 02:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR/
DIRECTOR:		SHANNON BROWNFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 137CENSUS: 60DATE:
01/15/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Health and Wellness Director, Melanie Fenn, and Executive Director, Mike SharkeyTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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At approximately 9:20AM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to continue a 1 Year Required Visit, and met Health and Wellness Director (HWD), Melanie Fenn. Executive Director (ED), Mike Sharkey, arrived during visit at approximately 11:30AM. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs was informed that there were 32 residents in Assisted Living and Memory Care with 28 Independent Living residents for a total of 60 residents in care. LPAs was also informed that there were 26 staff members on-site.

LPAs reviewed the Facility's Staff Roster with HWD and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed staff files and resident medication. During staff file review, LPAs observed that 5 of 5 staff files had CPR certification, and 4 of 5 staff files were missing proof of first aid certification. Health and Safety Code 1569.618(c)(3), states that at least one staff member on-site is required to have first aid and CPR certification training. Per discussion with HWD, there is a nurse on every shift that has their first aid certification. LPAs observed proof of first aid certification for facility nurses during visit. HWD and ED informed LPAs that they will ensure all staff have their first aid certification (technical advisory issued, LIC9102, Health and Safety Code, 1569.618(c)(3)). Medication was centrally stored and secure.

During visit, LPAs were informed that facility has a new Executive Director, Mike Sharkey, as of 12/30/2024. LPAs requested Administrator paperwork to be submitted to the Santa Rosa Regional Office in order to process the change of administrator. LPAs requested the following documents to be submitted for review:
Administrator Documents
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ALDERSLY
FACILITY NUMBER: 216801686
VISIT DATE: 01/15/2025
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Continued from LIC809

Administrator Documents Continued
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of Negative TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)


LPAs are requesting the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 02/15/2025.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation) discussed and provided to Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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