ALMAVIA OF SAN RAFAEL

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

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, 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.

Official plan of correction

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.

Deadline recorded: Apr 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, Licensee did not comply with the section cited above. LPA observed two residents with medications in their room that should have been centrally stored and inaccessible. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee to distribute a copy of medication reminder notice to all residents and responsible parties. Copy of notice to be submitted to Community Care Licensing by POC due date of 04/17/2026.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, Licensee did not comply with the section cited above. Five instances of expired foods were observed in facility's arts and crafts refrigerator and activity cabinets, including expired milk, cheese, canned frosting, blueberries, opened boxed beef broth, and chocolate sauce. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/27/2026 Plan of Correction Licensee to conduct in-service training for Activity Enrichment staff on standards and expectations. 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.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(a)A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: based on record review, Licensee did not comply with the section cited above and did not ensure that medication was administered to R1 as required. R1 was not administered multiple medications due to it being unavailable or awaiting refill. This is an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to submit self-certification that in-service training will be conducted for all staff that administer medications by POC due date of 02/25/2026. Training to review Resident 6 rights, medication refills, and PIN 19-21-ASC. Licensee to ensure that epinephrine pens is completed. Training to include: Date, Topic, Name/Job, Role, and Signatures. Proof of completed training to be submitted by 03/31/2026.

Deadline recorded: Feb 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: based on observations made and record review, the Licensee did not comply with the section above and did not ensure that R1 was provided their modified diet. This poses an immediate health & safety risk to the residents in care.

Official plan of correction

Licensee to submit self-certification that in-service training will be conducted for direct care staff and dining/kitchen staff by POC due date of 02/25/2026. Training to include: Date, Topic, Name/Job, Role, and Signatures. Proof of completed training to be submitted by 03/31/2026.

Deadline recorded: Feb 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

Licensee to submit self-certification that training will be conducted for management and direct care staff reviewing regulation by POC due date of 03/09/2026. Training to include: Date, Topic, Name/Job Role, and Signatures. Proof of completed training to be submitted by POC due date of 03/31/2026.

Deadline recorded: Mar 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to the rights listed in Section 87468.1... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...this requirement was not met as evidenced by: based on record review and observations made, Licensee did not ensure that resident received weekly skin checks as agreed upon during a resident care conference.

Official plan of correction

Licensee to submit self-certification that training will be conducted for the Care Department reviewing documentation by POC due date of 03/09/2026. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Proof of completed training to be submitted by POC due date of 03/31/2026.

Deadline recorded: Mar 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

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 supporting documents to be submitted to CCL for review and approval by POC due date of 03/03/2026.

Deadline recorded: Feb 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87616(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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 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.

Deadline recorded: Feb 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

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.

Deadline recorded: Dec 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465(a)(5) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on statement from facility Administrator, staff did not ensure 16 residents received their medication timely. Subsequently, 16 residents missed medication which poses an immediate health and safety risk to residents in care.

Official plan of correction

Plan of Correction already fullfilled with training with all staff that pass medication. LPA obtained copies. POC cleared.

Deadline recorded: Mar 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering. This requirement was not met as evidenced by: Based on record review the facility didn't comply with this section for 1of1 residents which poses an immediate Health, Safety risk to residents in care. Resident R1 isn't allowed to leave facility unassisted; left on 01/01/2022 through the egress doors after an associate left through the same door. Resident was found at the gas station by local law enforcement.

Official plan of correction

Facility agrees to address frequency of AWOL drills for staff. In addition, to conduct staff training regarding elopement, wandering and ensuring that all Memory Care Unit doors are secured. Proof of training with participants signature, trainer & date of training already submitted to CCL during Case Management.

Deadline recorded: Feb 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not met as evidenced by: Based on an email conversation dated for July 23, 2021, it was disclosed that facility missed a Urinalysis order for R1 in May 2021. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure that residents receive assistance with getting to and from scheduled medical appointments as needed. Administrator to arrange for care staff and all health care staff including med techs (in-service) training regarding adhering to Medical Appointments in addition to submitting a plan of future compliance of how they will prevent residents missing appointments moving forward. Plan of training and plan of future compliance shall be furnished to the Department of Social Services-Community Care Licensing Division to the Rohnert Park CCL office by POC date of September 30, 2021. Proof of training including sign-in sheet to be submitted to Rohnert Park CCL office by October 12, 2021.

Deadline recorded: Sep 30, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. (C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met evidenced by: Based on interviews with facility staff, and research of incident reports submitted for Almavia of San Rafael to CCL, did not properly report an incident to the CCL as required by Title 22 regulation. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator to arrange for in-service training for staff regarding Reporting Requirements. Report and plan for training to be submitted to Rohnert Park CCL office by POC date of October 6, 2021. Proof of training along with a sign-in sheet shall be furnished to Rohnert Park CCL office by October 12, 2021.

Deadline recorded: Oct 6, 2021. A deadline is not proof that correction was completed.