216801868-6-5-2025-21-AS-VBEI-DHSSCV-20250619134606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 06/05/2025
Date Signed: 06/05/2025 03:51:23 PM

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
02/24/2025 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20250224112540

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: 117	DATE:	06/05/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Executive Director/Administrator, Angie Boucher-Turin		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained an unexplained injury while in care.
Staff did not report an incident involving resident as necessary.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 3:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with met with Executive Director/Administrator, Angie Boucher-Turin.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “Resident sustained an unexplained injury while in care, and “Staff did not report an incident involving resident as necessary.” Complainant alleged that Resident 1 (R1) was subjected to physical abuse by facility staff while residing at the facility and that R1’s responsible party was not notified of an incident that occurred in April 2023. Additional information from Complainant stated that R1 had been isolating in their room due to testing positive for COVID-19 and was found to have a broken femur after they went to the emergency room. Complainant also stated that emergency room physician suspected abuse based on their observations of R1’s injury at the hospital.
Continued on LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 2

Control Number 21-AS-20250224112540

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: ALMAVIA OF SAN RAFAEL	FACILITY NUMBER: 216801868
	VISIT DATE: 06/05/2025

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
26
27
28
29
30
31
32

Continued from LIC9099

Community Care Licensing (CCL) received an incident report on 04/14/2023. Report stated that on 04/13/2023, R1 was observed by facility staff to have swollen feet and skin discoloration on their right leg. Per report received, facility staff notified R1’s responsible party via phone call and contacted Emergency Services for further evaluation. Facility progress note stated that on 04/13/2023, facility staff observed R1’s knee to be swollen and bruised, and when touched, R1 exhibited pain. Progress note also stated that facility staff notified R1’s responsible party and sent a text message of their observations to the responsible party and contacted emergency services. Review of documentation showed that R1 did not have an SOC-341 or abuse report filed in April 2023 by the hospital or other entities. Interview conducted with Witness 1 (W1) revealed that facility protocol is to contact the resident’s primary responsible party. If the primary responsible party is unavailable, then the facility is to contact the secondary responsible party. W1 was unable to recall any additional details of R1’s incident. Interview conducted with Witness 2 (W2) did not reveal any additional information as they were unable to recall details of R1’s incident.

Facility documentation indicated that facility maintenance Director reviewed the video camera system and did not observe R1 to have a fall. LPA was unable to review the video footage as the facility camera system only archives up to 90 days and the incident occurred on April 13, 2023.

Due to lack of evidence, the Department is unable to determine if there was a violation of Title 22 Regulation, therefore, these allegations are Unsubstantiated.

A finding that the complaint allegation 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.

Exit interview conducted. Copy of report 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: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2