216801868-2-3-2026-21-AS-VBEI-DRLPPP-20260224102948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 02/03/2026
Date Signed: 02/03/2026 03:46:06 PM

Substantiated

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
12/22/2025 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20251222134309

FACILITY NAME:	ALMAVIA OF SAN RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR:	CARLA SANCHEZ		FACILITY TYPE:	740
ADDRESS:	515 NORTHGATE DRIVE		TELEPHONE:	(415) 491-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	160	CENSUS: 105	DATE:	02/03/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director, Tracy Freudendahl, and Health and Wellness Director, Stephanie Judd		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff retained a resident with a prohibited health condition
Staff did not seek timely medical care for resident in care

INVESTIGATION FINDINGS:

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At approximately 12:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Executive Director, Tracy Freudendahl, and Health and Wellness Director, Stephanie Judd.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff retained a resident with a prohibited health condition, and Staff did not seek timely medical care for resident in care.” Complaint alleged that Resident 1 (R1) was observed to have a wound that looked to be a Stage 3 pressure injury which was not allowed in licensed Residential Care Facilities for the Elderly (RCFEs). Per complaint, facility management became aware of the wound on 12/18/2025 and R1 was observed to still be at the facility on 12/21/2025. Complaint stated that R1’s wound had an odor, that caregivers were wearing masks because the smell was overwhelming, and that facility staff provided showers for R1, but there was no documentation
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20251222134309

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: 02/03/2026

NARRATIVE

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Continued from LIC9099

of the wound. Complainant further stated that they didn't know how or when R1's injury occurred and didn't know if R1's home health agency or primary care physician had been notified.

Review of R1’s progress notes showed that on 12/17/2025, facility caregivers observed that R1 had a big wound on their bottom. These notes further stated that the wound was observed to be an open hole, that it looked very bad, and was leaking a white liquid.

R1’s nursing progress notes stated the following entries:

· On 12/17/2025, a late entry was inputted to note that R1’s home health agency provided wound care with no additional details.

· On 12/18/2025, facility notes stated that R1’s responsible party was contacted and that R1’s home health agency was providing wound care three times per week. Per notes, facility would communicate with R1’s primary care physician regarding intervention or in-house treatment.

· On 12/20/2025, a late entry was inputted to note that R1’s home health agency provided wound care with no additional details.

· On 12/21/2025, the resident care director and health care coordinator contacted R1's Primary Care Physician via a fax communication. Per fax communication, facility asked for further advice as it was believed that R1 had a stage 3 pressure wound and they wanted an update on R1’s hospice referral.

Review of R1’s physician fax communication for 12/21/2025 stated that R1 had a wound that appeared to be a Stage 3 and that it was getting worse even though R1 had been receiving home health services. Fax further requested for a status update on R1’s hospice referral as being a licensed facility meant that R1 would need to be receiving hospice services if the facility were to retain a resident with a Stage 3 wound.

Interview conducted with Resident Care Director (RCD) revealed that on 12/22/2025, emergency personnel (EMS) arrived at the facility to send R1 to the hospital. Per RCD, no one at the facility contacted EMS on 12/22/2025 and emergency personnel informed them that they received an anonymous phone call for R1.

The Department observed that the facility did not request or submit any documentation for an exception for R1 to stay at the facility once it was believed that R1 could have had a stage 3 pressure injury on 12/21/2025. Review of R1's medical records showed that R1 was diagnosed with a Stage 4 pressure injury on 12/22/2025.

Continued on LIC9099C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20251222134309

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: 02/03/2026

NARRATIVE

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Continued from LIC9099

Based on interviews conducted, record review, and observations made, these allegations are Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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.

**An immediate Civil Penalty in the total amount of $500 has been issued for not seeking timely medical care (See LIC-421IM). An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).**

Exit interview conducted. Copy of report, 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: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20251222134309

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/04/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...This requirement was not met as evidenced by: based on records, interviews and observations, Licensee did not ensure that	1 2 3 4 5 6 7	Licensee to submit self-certification that in-service training will be conducted reviewing the regulation, 87466 Observation of the Resident. Self-Certification to be submitted by POC due date of 02/04/2026. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training and
	8 9 10 11 12 13 14	Resident 1 (R1) received timely medical care. R1's pressure injury was observed to be a big hole, very bad looking, and was leaking a white liquid on 12/17/25. R1 did not receive medical care until 12/22/25. This poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14	supporting documents to be submitted to CCL for review and approval by POC due date of 03/03/2026.
Type B 02/16/2026 Section Cited CCR 87616(a)	1 2 3 4 5 6 7	87616 Exceptions for Health Conditions (a) ...the licensee may submit a written exception request if he/she agrees that the resident has a prohibited... health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide a written plan to CCL outlining their intended training schedule. Plan to be submitted by POC due date of 02/16/2026. In-service training for all direct staff on the following regulations: 87616 Exceptions for Health Conditions and 87615 Prohibited Health Conditions. Training to
	8 9 10 11 12 13 14	based on record review, interviews, and observations, Licensee did not submit the proper paperwork to Community Care Licensing once it was believed that R1 had a Stage 3 wound. R1 was then diagnosed with a Stage 4 wound. This is a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training and supporting documents to be submitted toCCL for review and approval by POC due date of 03/03/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

LIC9099 (FAS) - (06/04)

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