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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 04/16/2026
Date Signed: 04/17/2026 07:32:00 AM

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
02/25/2026 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20260225083835
FACILITY NAME:ALMAVIA OF SAN RAFAELFACILITY NUMBER:
216801868
ADMINISTRATOR:TRACY FREUDENDAHLFACILITY TYPE:
740
ADDRESS:515 NORTHGATE DRIVETELEPHONE:
(415) 491-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:160CENSUS: 116DATE:
04/16/2026
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Executive Director, Tracy Freudendahl, Resident Services Director, Elvira Suciu, and Resident Care Director, Isabel SaunduvsTIME COMPLETED:
06:05 PM
ALLEGATION(S):
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Staff do not answer residents calls for assistance timely
INVESTIGATION FINDINGS:
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At approximately 8:55AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Tracy Freudendahl, Resident Services Director, Elvira Suciu, and Resident Care Director, Isabel Saunduvs.

During the course of the investigation, the Department requested and reviewed documents and made observations. The following allegation was investigated, “Staff do not answer residents calls for assistance timely.” Complaint alleged that on 02/22/2026, Resident 1 (R1) did not receive help in the morning. Report stated that facility staff did not arrive even though R1 pressed their pendant and waited.

Continued on LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
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-20260225083835
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: 04/16/2026
NARRATIVE
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Continued from LIC9099

R1’s facility pendant call logs for 02/21/2026 through 02/23/2026 were requested. Review R1’s pendant log for 02/21/2026 and 02/22/2026 showed evidence of late response times. The following was observed:

· On 02/21/2026, R1’s pendant was pressed at 4:07AM and was not cleared until 5:00AM. Log reported that 52 minutes had lapsed.

· On 02/22/2026, R1’s pendant was pressed at 12:30AM and was not cleared until 7:35AM. Log reported that 424 minutes had lapsed.

· On 02/22/2026, R1’s pendant was pressed at 7:57AM and was not cleared until 8:57AM. Log reported that 60 minutes had lapsed.

· On 02/22/2026, R1’s pendant was pressed at 7:54PM and was not cleared until 8:42PM. Log reported that 48 minutes had lapsed.

Based on record review and observations made, this allegation is 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 deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

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

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260225083835
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: 04/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to...Section 87468.1... residents...shall have...following personal rights: (4) To care, supervision, and services that meet their...needs and are delivered by staff that are sufficient in numbers,
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Licensee to conduct in-service training regarding expectations on answering resident pendant calls timely. Training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. Training to be submitted for review and approval by POC due date of 04/27/2026.
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qualifications & competency...Requirement was not met as evidenced by: based on record review, Licensee did not comply with section cited above & did not ensure that R1's pendant call was responded to timely. This poses a potential health/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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3