Inspection Reports for Aldersly
326 Mission Ave, San Rafael, CA 94901, United States, CA, 94901
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, reflecting a generally clean and compliant facility. Several complaint investigations were unsubstantiated, including allegations about staffing, care, and cleanliness. However, some deficiencies were cited over time, primarily involving safety measures for residents with dementia, medication storage and handling, and timely response to resident needs. The facility received a $1,000 civil penalty for repeat safety violations related to resident elopements in October 2023, and another $1,000 penalty in October 2024 for a similar issue. The most recent inspection on October 21, 2025, found medication storage and handling deficiencies but no immediate jeopardy or fines, indicating some ongoing areas needing improvement.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 82
Capacity: 172
Deficiencies: 3
Oct 21, 2025
Visit Reason
The inspection was an unannounced 1 Year Required Visit (annual inspection) conducted to evaluate compliance with licensing regulations and facility operations.
Findings
The inspection found deficiencies related to medication storage and handling, including medications not being centrally stored as required, medication cart keys being accessible and the cart unlocked, and noon medications being pre-poured early. Plans of correction were required to address these issues.
Severity Breakdown
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| One of six residents had three medications that were not centrally stored as required. | — |
| Medication cart keys were accessible and the cart was unlocked and accessible to guests and residents. | Type B |
| Noon medications were pre-poured at around 9AM, which is a technical violation. | — |
Report Facts
Staff on-site: 27
Residents in Assisted Living: 14
Residents in Memory Care: 17
Residents in Extended Care: 3
Residents in Independent Living: 48
Medications reviewed: 6
Medications not centrally stored: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sourabh Singh | Resident Care Manager | Met with during inspection |
| Eliana Lopez | Business Office Manager | Met with during inspection |
| Melanie Fenn | Health and Wellness Director | Met with during inspection and received report documents |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection |
| Victoria Bertozzi | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 76
Capacity: 172
Deficiencies: 1
Oct 3, 2025
Visit Reason
The inspection was an unannounced required 1 Year visit to evaluate compliance with licensing regulations for the Aldersly Facility.
Findings
The facility was found generally clean, safe, and compliant with infection control, food supply, and safety equipment requirements. However, a deficiency was cited for failure to timely assist a resident after a fall, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure Resident 1 was helped in a timely manner after a fall alerted by the Safely You Video System; resident was on the floor for over 2 hours. | Type A |
Report Facts
Staff on-site: 22
Residents in care: 76
Capacity: 172
Hot water temperature sample size: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mike Sharkey | Executive Director | Arrived during visit and participated in walkthrough |
| Sourabh Singh | Resident Care Manager | Met with Licensing Program Analyst and participated in walkthrough |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Oversaw licensing program and named in report |
Inspection Report
Census: 63
Capacity: 137
Deficiencies: 0
Aug 20, 2025
Visit Reason
The visit was an unannounced Case Management - Other inspection to evaluate the facility's completed expansion and updated capacity.
Findings
The facility's expansion was inspected, including a four-story building with 35 bedrooms for independent living residents. No deficiencies were cited during the visit, and the change of capacity to 172 non-ambulatory residents was approved effective the date of the visit.
Report Facts
Capacity change: 172
Current census: 63
Original capacity: 137
Number of bedrooms in expansion: 35
Water temperature sample size: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mike Sharkey | Executive Director | Met with Licensing Program Analyst during inspection and referenced regarding facility expansion |
| Melanie Fenn | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 60
Capacity: 137
Deficiencies: 0
Jan 15, 2025
Visit Reason
The inspection was an unannounced annual case management continuation visit to evaluate compliance with licensing requirements and facility operations.
Findings
The facility was found to be in compliance with no deficiencies cited during the visit. Staff files were reviewed, confirming CPR certification for all staff but noting some missing first aid certifications, which the facility plans to address. Medication storage was secure, and required documents were requested for updating the facility file.
Report Facts
Staff on-site: 26
Staff files reviewed: 5
Staff missing first aid certification: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Fenn | Health and Wellness Director | Met during inspection and discussed staff certifications |
| Mike Sharkey | Executive Director | New Executive Director as of 12/30/2024, met during inspection |
Inspection Report
Follow-Up
Census: 63
Capacity: 137
Deficiencies: 1
Oct 15, 2024
Visit Reason
The visit was an unannounced 1 Year Required Follow-Up Visit to evaluate compliance and follow up on previously self-submitted incident reports and deficiencies.
Findings
The facility was found generally compliant with regulations including staff background checks, infection control, and safety measures. However, a deficiency was cited for failure to prevent elopement of a resident with dementia, which posed an immediate health and safety risk. A civil penalty of $1,000 was issued for a repeat violation related to safety measures for residents with dementia.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident 3 eloped from the facility despite having a dementia diagnosis and being unable to leave unassisted, indicating failure to meet safety measures for residents with dementia. | Type A |
Report Facts
Civil Penalty Amount: 1000
Staff on site: 26
Hot water temperature range: 105
Hot water temperature range: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director/Administrator | Met with Licensing Program Analyst during inspection. |
| Melanie Fenn | Health and Wellness Nurse | Met with Licensing Program Analyst during inspection and received documents. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Victoria Bertozzi | Licensing Program Manager | Supervised the inspection and signed the report. |
Inspection Report
Census: 73
Capacity: 137
Deficiencies: 0
Feb 29, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on incident reports that were self-reported to Community Care Licensing.
Findings
The facility reported an incident involving a resident with a stage two coccyx wound. The facility provided first aid, made appropriate notifications, and arranged for specialist care. No deficiencies were cited during the visit.
Report Facts
Incident report date: Feb 21, 2024
Incident report submission date: Feb 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director/Administrator | Met with Licensing Program Analyst during visit and discussed incident report |
| Melanie Fenn | Health and Wellness Nurse | Met with Licensing Program Analyst during visit and discussed incident report |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 137
Deficiencies: 0
Feb 29, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that the facility failed to meet a resident's care needs, including not showering the resident, not providing incontinence care, and not administering suppository medication, which allegedly resulted in sepsis and hospitalization.
Findings
The investigation found insufficient evidence and documentation to substantiate the allegations. Interviews and document reviews did not confirm violations of care standards. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged failure to meet Resident 1's care needs, including lack of showering, incontinence care, and suppository medication administration, resulting in sepsis and hospitalization. The complaint was found unsubstantiated due to lack of evidence.
Report Facts
Capacity: 137
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director/Administrator | Met with Licensing Program Analyst during investigation |
| Melanie Fenn | Health and Wellness Nurse | Met with Licensing Program Analyst during investigation |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 67
Capacity: 137
Deficiencies: 0
Dec 6, 2023
Visit Reason
The visit was an unannounced continuation of a Required 1 Year annual case management inspection to evaluate the facility's compliance and update facility records.
Findings
The Licensing Program Analyst reviewed staff and resident files, medication storage, and certifications, finding all documentation well organized and compliant. Several facility documents were requested for update and submission by a specified due date.
Report Facts
Staff on-site: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director/Administrator | Met with Licensing Program Analyst during inspection |
| Melanie Fenn | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Enforcement
Capacity: 137
Deficiencies: 1
Oct 18, 2023
Visit Reason
The visit was an informal meeting conducted to address incidents involving resident elopements during community outings and on facility grounds, including a repeat violation related to safety measures for residents with dementia.
Findings
The facility failed to comply with safety requirements for residents with dementia, resulting in two elopement incidents. A civil penalty of $1,000 was issued due to a repeat violation of Regulation 87705(b)(2) within a 12-month period.
Deficiencies (1)
| Description |
|---|
| Failure to implement safety measures for residents with dementia, evidenced by Resident 2 eloping from the facility and being found two blocks away. |
Report Facts
Civil penalty amount: 1000
Total licensed capacity: 137
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Administrator/Executive Director | Met during the informal meeting and received report documents |
| Melanie Fenn | Health and Wellness Director | Met during the informal meeting |
| Kimberley Mota | Licensing Program Manager | Conducted the informal meeting and signed the report |
| Caitlynn Felias | Licensing Program Analyst | Conducted the informal meeting and signed the report |
Inspection Report
Annual Inspection
Census: 71
Capacity: 137
Deficiencies: 1
Sep 26, 2023
Visit Reason
Unannounced 1 Year Required Visit to evaluate compliance with regulations for an assisted living and memory care facility.
Findings
The facility was generally found to be clean, safe, and compliant with regulations including infection control, food supply, and safety equipment. However, a deficiency was cited related to the safety measures for residents with dementia after a resident went missing during a community outing.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement adequate safety measures for residents with dementia, evidenced by a resident (R1) missing for approximately 7 hours during a community outing. | Type A |
Report Facts
Staff on-site: 21
Residents on community outing: 5
Staff on community outing: 3
Deficiencies cited: 1
Plan of Correction Due Date: Sep 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director/Administrator | Met with Licensing Program Analysts during inspection and discussed incident. |
| Caitlynn Felias | Licensing Program Analyst | Conducted inspection and signed report. |
| Kimberley Mota | Licensing Program Manager | Named as supervisor and licensing program manager on report. |
Inspection Report
Follow-Up
Census: 77
Capacity: 137
Deficiencies: 1
Apr 21, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced case management visit to follow up and cite deficiencies discovered during a prior complaint investigation, including review of a death report and incidents involving residents.
Findings
The visit found that two incidents of resident falls were not reported to the licensing agency within the required 7 days, and death reports for two residents were submitted late. Law enforcement was not contacted regarding one resident's incident, and further investigation is needed.
Complaint Details
The visit followed up on a complaint investigation related to a death report and incidents involving residents, including unreported falls and delayed death reports. The substantiation status is not explicitly stated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that the licensing agency was notified of two incidents involving resident falls within 7 days as required by reporting regulations. | Type B |
Report Facts
Capacity: 137
Census: 77
Deficiency count: 1
POC Due Date: May 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Administrator | Met with Licensing Program Analyst during the visit |
| Marisol Cuadra | Licensing Program Analyst | Conducted the case management visit and cited deficiencies |
| Bethany Moellers | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the evaluation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 137
Deficiencies: 1
Apr 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including staff not following a resident's feeding plan, inadequate supervision, failure to implement fall risk measures, improper food disposal, and medication administration issues.
Findings
The investigation substantiated the allegation that staff did not follow a resident's feeding plan, posing an immediate health and safety risk. Other allegations regarding inadequate supervision, fall risk measures, food disposal, and medication administration were found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not follow the resident's feeding plan, based on evidence including a food tray left uneaten next to a resident with swallowing difficulties and a care plan error. Other allegations such as inadequate supervision, fall risk measures, food disposal, and medication administration were unsubstantiated due to lack of preponderance of evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide modified diets prescribed by a resident's physician as a medical necessity. | Type A |
Report Facts
Facility capacity: 137
Resident census: 77
Plan of Correction due date: Apr 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Shannon Brown | Administrator | Facility administrator met during investigation and involved in findings delivery |
Inspection Report
Census: 82
Capacity: 137
Deficiencies: 0
Mar 9, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on incident reports that were self-reported to Community Care Licensing.
Findings
The inspection reviewed three incident reports involving resident safety and potential financial abuse. The facility made appropriate notifications and took actions such as suspending a private caregiver pending investigation. No deficiencies were cited during the visit.
Report Facts
Incident Report #1: 1
Incident Report #2: 1
Incident Report #3: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director/Administrator | Met during inspection and discussed incidents |
| Melanie Fenn | Charge Nurse | Met during inspection and discussed incidents |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 137
Deficiencies: 0
Mar 9, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff were not providing resident's files to the resident's authorized representative.
Findings
The allegation was found to be unfounded as the Licensing Program Analyst was unable to identify any deficiencies on the Assisted Living side of the facility where jurisdiction applies. No deficiencies were cited during the visit.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.
Report Facts
Capacity: 137
Census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director/Administrator | Met with Licensing Program Analyst during complaint investigation |
| Melanie Fenn | Charge Nurse | Met with Licensing Program Analyst during complaint investigation |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Census: 78
Capacity: 137
Deficiencies: 0
Feb 7, 2023
Visit Reason
The visit was an unannounced Case Management - Other visit to follow up on a plan of correction cited on 12/29/2022 and to review expectations for annual visits.
Findings
No deficiencies were cited during the visit. Discussions included incident reports, call light system audit, annual expectations, updating staff and resident files, and staff training.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during the visit |
| Melanie Fenn | Charge Nurse | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 137
Deficiencies: 0
Feb 7, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation of neglect/lack of supervision resulting in a resident sustaining unexplained injuries.
Findings
The investigation found inconsistent information from residents and staff regarding the alleged injuries. Review of records and observations did not substantiate the allegation. Therefore, the complaint was determined to be unsubstantiated with no deficiencies cited during the visit.
Complaint Details
The complaint involved an allegation of neglect/lack of supervision resulting in a resident sustaining unexplained injuries, specifically a gash on the resident's scalp and bruising on their cheek. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 137
Census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during investigation |
| Melanie Fenn | Charge Nurse | Met with Licensing Program Analyst during investigation |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 137
Deficiencies: 0
Feb 7, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff do not provide enough liquids to residents and that staff did not report a resident's incident to the resident's authorized representative.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations and interviews indicated that staff offer drinks and snacks regularly, and information about reporting the incident to the authorized representative was inconsistent. Therefore, both allegations were unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint was unsubstantiated based on lack of preponderance of evidence to prove the alleged violations occurred. Allegations included inadequate liquid provision to residents and failure to report an incident to a resident's authorized representative.
Report Facts
Capacity: 137
Census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during investigation |
| Melanie Fenn | Charge Nurse | Met with Licensing Program Analyst during investigation |
| Gilbert Carrasco | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 137
Deficiencies: 1
Dec 29, 2022
Visit Reason
The inspection was an unannounced Case Management - Deficiencies visit conducted to investigate a complaint dated September 7, 2022, regarding failure to report a resident fall incident and other incident reporting deficiencies.
Findings
The facility failed to report a resident fall resulting in a fracture and did not submit incident reports for November to December 2022 as required. An immediate civil penalty was issued for repeat violations of reporting requirements under California Code of Regulations Section 87211.
Complaint Details
The visit was complaint-related based on a complaint dated September 7, 2022. The complaint was substantiated by findings that the facility did not report a resident fall incident and failed to submit incident reports for November and December 2022.
Deficiencies (1)
| Description |
|---|
| Failure to submit required incident reports to Community Care Licensing within seven days of occurrence, posing a potential health and safety risk to residents. |
Report Facts
Civil penalty amount: 250
Daily penalty accrual: 100
Plan of Correction due date: Jan 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during inspection |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 137
Deficiencies: 1
Dec 29, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that the facility does not have adequate staff to meet resident needs and staff do not respond to resident emergency call buttons in a timely manner.
Findings
The investigation substantiated the allegations that staff did not respond to emergency call buttons in a timely manner and that the facility lacked adequate staffing. Call button logs showed wait times of an hour or more, and interviews revealed issues with defective pendant devices and delayed staff responses, posing an immediate risk to resident health and safety.
Complaint Details
The complaint was substantiated based on documents reviewed, observations, and interviews. The allegations that staff do not respond to resident emergency call buttons in a timely manner and that the facility does not have adequate staff to meet resident needs were validated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87411(a) Personnel Requirements – Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met as evidenced by staff unable to respond to resident care needs and call buttons in a timely manner, with multiple call buttons having response times of an hour or longer and issues with defective pendants. | Type A |
Report Facts
Capacity: 137
Census: 81
Deficiency Type A: 1
Plan of Correction Due Date: Dec 30, 2022
Plan of Correction Due Date: Jan 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during investigation |
| Melanie Fenn | RN | Participated during delivery of findings |
| Gilbert Carrasco | Administrator | Facility administrator receiving report and plan of corrections |
| Hope DeBenedetti | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 80
Capacity: 137
Deficiencies: 0
Nov 8, 2022
Visit Reason
The inspection was an unannounced Required - 1 Year Visit focused on the Infection Control procedures and practices of the facility.
Findings
The facility was found to be clean, with proper COVID-19 signage, hand-washing signs, and staff wearing masks. The facility maintained a cleaning and disinfecting schedule, had adequate PPE and medication supplies, and had up-to-date fire safety inspections and disaster drills. No deficiencies were cited during the visit.
Report Facts
Capacity: 137
Census: 80
PPE supply duration: 30
Fire extinguisher last serviced: 2022
Fire inspections dates: Fire inspections conducted on September 22, 2021 and November 1, 2022
Disaster drill date: Last facility disaster drill conducted October 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Momo Duoa | Administrator | Met with Licensing Program Analyst during inspection |
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during inspection |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 137
Deficiencies: 0
Nov 1, 2022
Visit Reason
The visit was conducted to discuss the facility's dementia care program and to review supporting documents for submission to Community Care Licensing.
Findings
No deficiencies were cited during the visit. An exit interview was conducted and the report was discussed and provided to the Administrator.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Momo Duoa | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 137
Deficiencies: 0
Oct 3, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/20/2022 regarding a resident fall resulting in facial injuries, lack of cleanliness, and lack of staffing at the facility.
Findings
The investigation found that the facility followed its fall procedures and no evidence supported the allegations of lack of cleanliness or staffing. The complaint allegations were determined to be unsubstantiated due to insufficient evidence to prove or disprove the violations.
Complaint Details
The complaint included allegations of a resident fall causing facial injuries, lack of cleanliness, and lack of staffing. After multiple tours and interviews, the Licensing Program Analyst found no preponderance of evidence to substantiate these allegations, resulting in an unsubstantiated finding.
Report Facts
Facility capacity: 137
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during the investigation |
| Gilbert Carrasco | Administrator | Facility Administrator named in the report |
Inspection Report
Census: 27
Capacity: 137
Deficiencies: 0
Sep 13, 2022
Visit Reason
The visit was an unannounced Case Management - Other visit to follow up on Change of Administrator paperwork needed for the Executive Director, Shannon Brown.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst conducted a walk-through of the facility and discussed the report with the Administrator during the exit interview.
Report Facts
Capacity: 137
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Brown | Executive Director | Met during the visit and is the Back-Up Administrator |
| Momo Duoa | Resident Care Director | Current Administrator overseeing the facility |
| Melanie Fenn | Nurse | Accompanied Licensing Program Analyst during walk-through |
| Felias | Licensing Program Analyst | Conducted the unannounced visit |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 137
Deficiencies: 1
Jul 7, 2022
Visit Reason
The inspection was an unannounced Case Management - Deficiencies visit conducted to investigate a complaint regarding resident personal rights.
Findings
A deficiency was found where a trash bag was tied around Resident #1's closet, preventing access to clothing, which violated personal rights and presented an immediate health and safety risk.
Complaint Details
The visit was complaint-related and substantiated by the observation of the trash bag restricting Resident #1's access to clothing, violating personal rights.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A trash bag was tied around Resident #1's closet preventing access to clothing, violating personal rights and posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 137
Census: 82
Plan of Correction Due Date: Jul 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Shannon Brown | Executive Director | Met with Licensing Program Analyst during inspection and removed the trash bag |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 137
Deficiencies: 1
Apr 5, 2022
Visit Reason
The inspection was conducted as a Case Management-Deficiencies visit following a complaint investigation dated January 4, 2022, regarding an unreported fall incident at the facility.
Findings
The facility failed to report a resident's fall incident to the licensing agency as required by California Code of Regulations Title 22, and incidents were not documented on the required Unusual Incident Reports (LIC 624). This failure poses a potential health, safety, or personal rights risk to persons in care.
Complaint Details
The complaint investigation was substantiated by findings that a resident sustained a fall that was unreported to licensing and incidents were not documented on LIC 624/Unusual Incident Reports.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly report an incident to the licensing agency as required by Title 22 regulation. | Type A |
Report Facts
Capacity: 137
Census: 35
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Hope DeBenedetti | Licensing Program Manager | Named as supervisor and licensing program manager |
| Momo Dua | Staff Member | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 137
Deficiencies: 0
Apr 5, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including residents falling multiple times while in care, sustaining minor injuries, unqualified staff providing care, inadequate laundry service, and unmet hygiene needs.
Findings
The investigation found that although some falls and minor injuries occurred, and a newly hired Medication Technician was still in training, there was insufficient evidence to substantiate the allegations. Laundry and hygiene concerns were not supported by consistent information. Overall, the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents falling multiple times and sustaining minor injuries, unqualified staff providing care, inadequate laundry service, and unmet hygiene needs. Evidence did not prove the alleged violations occurred.
Report Facts
Capacity: 137
Census: 35
Wait time: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation |
| Momo Dua | Staff Member | Met with Licensing Program Analyst during investigation |
| Gilbert Carrasco | Administrator | Facility administrator named in report header |
Inspection Report
Census: 78
Capacity: 122
Deficiencies: 0
Feb 10, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced Case Management visit to review the physical plant for a capacity increase at the Aldersly facility.
Findings
No deficiencies were observed or cited during the inspection. The analyst toured the facility, verified fire safety compliance, and noted the licensee's request to increase capacity from 122 to 137 beds.
Report Facts
Capacity increase request: 15
Fire extinguisher inspection date: 202201
Rooms observed for capacity increase: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Carrasco | Administrator | Met with Licensing Program Analyst during inspection |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the facility evaluation inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 81
Capacity: 122
Deficiencies: 0
Sep 9, 2021
Visit Reason
The inspection was conducted as a Required 1-Year unannounced inspection to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, safe, and in compliance with regulations including fire safety, food provisions, and resident accommodations. No deficiencies were observed or cited during the inspection.
Report Facts
Hot water temperature range: 115.8
Hot water temperature range: 120
Fire extinguisher last charged: 2021
Smoke detector last inspection date: Jul 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Preet Kaur | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 122
Deficiencies: 0
Aug 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations that staff installed an inappropriate alarm on a resident's door and that the resident's responsible party was not notified of room modifications.
Findings
The investigation found the allegation regarding the inappropriate alarm to be unsubstantiated, as the alarm volume was adjusted promptly and did not cause stress to residents. The allegation that the resident's responsible party was not notified of room modifications was found to be unfounded, with documentation confirming notification was made.
Complaint Details
The complaint investigation was initiated due to allegations that staff installed an inappropriate alarm on a resident's door and that the resident's responsible party was not notified of room modifications. The alarm issue was addressed by lowering the volume, and the camera in the hallway did not infringe on residents' rights. The notification allegation was disproven by documentation and interviews. Both allegations were not substantiated.
Report Facts
Capacity: 122
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation |
| Hope DeBenedetti | Licensing Program Manager | Oversaw the complaint investigation |
| Preet Kaur | Administrator | Met with Licensing Program Analyst during investigation |
| Gilbert Carrasco | Administrator | Facility Administrator named in report header |
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