216803245-2-11-2022-21-AS-FSAI-CBJUJR-20220211143759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803245
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:38:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	COMFORTING HANDS FOREVER,LLC		FACILITY NUMBER:	216803245
ADMINISTRATOR:	BIERKE, EVERDINAH		FACILITY TYPE:	740
ADDRESS:	73 GOLDEN HINDE BLVD		TELEPHONE:	(415) 479-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	02/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Administrator, Everdinah Bierke		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Comforting Hands Forever,LLC unannounced for the purpose of conducting a Required- 1 year inspection. LPA was greeted at the door by Faye Canete. Administrator arrived 20 minutes later. LPA toured the facility on 02/11/2022 with Administrator, Everdinah Bierke. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were not equipped with auditory devices on 6 out of 6 exit doors. In addition, there were two doors with no auditory devices and that were taken down due to painting of interior of facility (See 809D). Fire Extinguisher was found to be last charged on 9/2021 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured at 107 degrees in the common restroom (between Room # 3 & 4) and at 90.1 degrees in Room #2 (See LIC 809D and photos) falling out of Title 22 acceptable regulation of 105 to 120 degrees F. In addition, Room #5 had a temperature of 140.1 degrees also falling out of Title 22 acceptable regulation of 105 to 120 . The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked garage. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. LPA requested an updated facility sketch. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply found by the front door. Facility was N95 Fit tested on December 2021. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COMFORTING HANDS FOREVER,LLC	FACILITY NUMBER: 216803245
	VISIT DATE: 02/11/2022

NARRATIVE

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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report was signed and given to the Administrator along with appeal of rights.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COMFORTING HANDS FOREVER,LLC	FACILITY NUMBER: 216803245
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 3 residents bathrooms. Room #2 fell out of regulation by not reaching temperatures of 105 to 120 degrees, temperature read 90.1 degrees. This regulation poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 02/25/2022
	Plan of Correction
1 2 3 4	Licensee to ensure water temperature is maintained within regulation - 105 TO 120 F. Licensee to submit a LIC 9098 seff certification that hot water temperature has been adjusted by POC date of 02/25/2022.

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 3 residents bathrooms. Room #5 which houses Hospice residents had a temperature of 140.1 degrees. In addition, facility had NO POSTED signs indicating that the temperature would reach above 125 degrees. This regulation poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/25/2022
	Plan of Correction
1 2 3 4	Licensee to either adjust water temperature or ensure if water temperature does exceed the 105-120 degrees that a sign needs to be posted that the temperature exceeds that high. Licensee to submit a LIC 9098 seff certification that hot water temperature has been adjusted by POC date of 02/25/2022.

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

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COMFORTING HANDS FOREVER,LLC	FACILITY NUMBER: 216803245
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(j)

87705(j) Care of Persons with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee failed to have auditory devices present &/or working properly in 6 of 6 exit doors which poses an immediate health, & safety risk to residents in care. LPA toured the facility with Administrator and tested/observed auditory devices not present and/or turned on in the facility and doors that lead to outside.
	POC Due Date: 02/14/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all door alarms are on & working appropriately at all times. Licensee to place and turn all auditory devices on. Licensee to submit LIC 9098 self certification with a written statement signed and dated. In addition, facility staff understands that auditory devices must be turned on at all times, and that all auditory devices are working properly to CCL by POC of 02/14/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

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