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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 07/01/2025
Date Signed: 07/03/2025 11:00:26 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250109161946
FACILITY NAME:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR:PERLES,JONATHANFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:137CENSUS: 60DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Health and Wellness Director, Melanie FennTIME COMPLETED:
10:15 PM
ALLEGATION(S):
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Personal Rights
Lack of staffing resulting in resident falls
Reporting requirements
Facility did not follow COVID protocols during an outbreak
INVESTIGATION FINDINGS:
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with and Wellness Nurse, Melanie Fenn.

During the course of the investigation, LPA requested and reviewed documents, conducted interviews, and made observations. LPA investigated the following allegations, “Personal Rights, Reporting Requirements, Facility did not follow COVID protocols during an outbreak, and Lack of Staffing resulting in resident falls.”

“Personal Rights” – Complainant alleged that facility staff shove and push Resident 1 (R1) and other residents to get them to go somewhere. Complainant also alleged that R1 has poor hygiene because R1 has been observed with food on their face before and after meals and has been observed with dirty hands/nails and wearing dirty/stained clothes. Review of R1’s Functional Assessment dated 03/21/2024 indicated that

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20250109161946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/01/2025
NARRATIVE
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Continued from LIC9099

they needed assistance with bathing and dressing, but was able to eat, walk and go to the bathroom independently. Review of R1’s Care Plan dated 08/08/2024 indicated that R1 could ambulate with a walker, required stand-by assist during showers, and needed verbal prompting and reminders for grooming and personal hygiene tasks. Interviews conducted with involved parties revealed conflicting statements. 8 of 9 interviews conducted stated that they did not observe R1 or other residents to be handled roughly. 2 of 9 interviews stated that R1 was observed to be in dirty clothes and have dirty hands and nails while 2 of 9 interviews were unable to provide additional information regarding R1’s care. 5 of 9 interviews stated that R1 was always observed to be clean and presentable. This allegation is Unsubstantiated.

“Reporting Requirements” - Complainant alleged that facility did not contact R1's responsible party timely after a fall where R1 hit their head. Review of facility incident report received by the Department on 01/08/2025 showed that R1 had a fall on 01/07/2025 and showed that R1’s responsible party was contacted on 01/08/2025 by phone. On 04/07/2025, the Department received email correspondence from the Complainant where they retracted their statement that R1’s responsible party was not contacted. Per email received, R1’s responsible party was contacted on 01/08/2025 and was left a voicemail by the facility. Per Title 22 Regulations, 87211(a)(1)(4), the facility notified the Department within the appropriate time frame of 7 days of the incident occurring. This allegation is Unsubstantiated.

“Facility did not follow COVID protocols during an outbreak” – Complainant alleged that facility did not follow COVID infection protocols during an outbreak that occurred July 2024. Review of Department’s system did not show reports of a COVID outbreak in July 2024 at the facility. Per California Department of Public Health, for employers, an outbreak was defined as “3 or more cases of COVID-19.” Interviews conducted with involved parties revealed conflicting statements. Some interviews stated that the facility had COVID at the end of July 2024 but were unable to recall how many cases there were while other interviews stated that the facility had two COVID cases or less at end of July 2024. Another interview stated that there was a COVID outbreak at the end of July 2024. This allegation is Unsubstantiated.

Continued on LIC9099C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250109161946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/01/2025
NARRATIVE
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Continued from LIC9099C

“Lack of Staffing resulting in resident falls” – Complainant alleged that facility is understaffed and cannot provide the supervision that R1 requires. Complainant stated that a private caregiver was hired to help R1. Review of R1’s Service Plan dated 08/08/2024 indicated that R1 had a history of falls and required assistance or verbal reminders when transferring or walking due to having an unsteady gait. Interviews conducted also revealed conflicting statements regarding R1’s care needs. Some interviews stated that R1 only required a stand-by assist or verbal prompting for their ADLs (Activities of Daily Living) while other interviews stated that R1 required two-person assistance with certain ADLs such as showers. Review of R1’s Service Plan does not state that R1 was a two-person assist. LPA conducted interviews with involved parties and received conflicting statements. 4 of 9 interviews conducted stated they felt that there wasn’t enough staffing because they had to wait to be let out of the facility or could not provide or recall additional information related to staffing concerns. 5 of 9 interviews stated that the facility had enough staff for R1’s care needs. This allegation is Unsubstantiated.

Based on interviews conducted, record review, and observations made, these allegations are Unsubstantiated.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
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