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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:32:43 PM

Document Has Been Signed on 11/22/2024 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ALMAVIA OF SAN RAFAELFACILITY NUMBER:
216801868
ADMINISTRATOR/
DIRECTOR:		ANGELA BOUCHER-TURINFACILITY TYPE:
740
ADDRESS:515 NORTHGATE DRIVETELEPHONE:
(415) 491-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 160CENSUS: 122DATE:
11/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Executive Director/Administrator, Angie Boucher-TurinTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Angie Boucher-Turin. The purpose of the visit was to follow up self-reported incidents that were submitted to Community Care Licensing (CCL).

The Santa Rosa Regional Office (SRRO) received 9 late incident reports from the facility. Review of reports showed that incidents occurred on the following dates: 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, and 11/03/2024. Reports were received by the SRRO on 11/12/2024. During LPA's visit, LPA discovered that Staff Member 1 (S1) did not submit the reports timely and that the Executive Director submitted the incident reports. Per Title 22 Regulations, incident reports must be submitted to CCL within seven (7) days of the incident occurring (deficiency cited, LIC809D, Regulation 87211(a)(1)).

LPA followed up on the following incidents:

Incident Report 1/SOC341: CCL received an incident report and SOC341 on 10/17/2024. Reports state that on 10/17/2024, Resident 1's (R1) family notified facility management of interactions between a facility staff member and Resident 1. Per R1's family, R1 stated to them that Staff Member 2 (S2) kissed them on two separate occasions. Facility made all appropriate notifications per regulation.

Incident Report 2/SOC341: CCL received an incident report and SOC341 on 11/13/2024. Reports state that on 11/12/2024, facility management was informed by Staff Member 3 (S3) that they observed Staff Member 4 (S4) pinch Resident 2's (R2) nose and raise a hand towards them. Per report, the incident occurred 2 months prior. Facility made all appropriate notifications per regulation.

Incident Report 3: CCL received an incident report on 11/20/2024. Reports state that on 11/18/2024, facility staff notified Executive Director that a former resident's medication was missing. Per report, the missing medications were discovered on 11/18/2024. Facility made all appropriate notifications per regulation.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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: ALMAVIA OF SAN RAFAEL
FACILITY NUMBER: 216801868
VISIT DATE: 11/22/2024
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Continued from LIC809

Per discussion with ED, internal investigations are ongoing and they have been in contact with the San Rafael Police Department regarding the incidents.

LPA requested and reviewed documents, and conducted interviews.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Confidential Names (LIC811) Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 02:32 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/22/2024 at 02:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ALMAVIA OF SAN RAFAEL
FACILITY NUMBER: 216801868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did
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Licensee to submit Inservice Training for management and direct care staff. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Training to be submitted tp CCL by POC due date of 12/02/2024.
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not comply with section cited above. Per record review, Licensee did not submit incident reports timely. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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