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Inspection visit

Routine inspection

ALMAVIA OF SAN RAFAELLicense 2168018682 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Executive Director, Tracy Freudendahl, Interim Resident Care Director, Elvira Suciu, and Resident Care Director, Isabel Saunduvs . Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 116 Residents in care and 35 staff members on-site. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Interim Resident Care Director and Resident Care Director and observed the following: Facility is a 3-story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. Emergency evacuation chairs were observed at facility stairwells. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 12 sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected November 2025. Facility's fire and sprinkler system was last inspected April 2026. Facility's emergency disaster plan was last reviewed and updated on 03/18/2026. During walkthrough, LPA observed multiple instances of expired food in the facility's art and crafts room. LPA, Interim Resident Care Director, and Resident Care Director, disposed of all items. LPA also observed over the counter (OTC) medications in two resident rooms. Continued on LIC809C Continued from LIC809 Review of facility's medication management program indicated that these two residents are receiving assistance with medications and therefore the medications should have been centrally stored. LPA discussed the following with Executive Director, Interim Resident Care Director, and Resident Care Director: Reporting Requirements PIN regarding 911 protocols PIN regarding dementia regulations LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. 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. Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87555(a)Type B

    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.

  • 87465(h)(2)Type A

    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.

  • 87468.2(a)(4)Type B

    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.

FAQ · About this visit

Common questions about this visit

What happened during the April 16, 2026 inspection of ALMAVIA OF SAN RAFAEL?

This was a inspection inspection of ALMAVIA OF SAN RAFAEL on April 16, 2026. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to ALMAVIA OF SAN RAFAEL on April 16, 2026?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "Based on observations made, Licensee did not comply with the section cited above. Five instances of expired foods were o..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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