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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803245
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:39:28 PM


Document Has Been Signed on 04/29/2024 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:COMFORTING HANDS FOREVER,LLCFACILITY NUMBER:
216803245
ADMINISTRATOR:BIERKE, EVERDINAHFACILITY TYPE:
740
ADDRESS:73 GOLDEN HINDE BLVDTELEPHONE:
(415) 479-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Staff Member, Faye CaneteTIME COMPLETED:
03:45 PM
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At approximately 12:05PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Faye Canete. Administrator/Licensee, Everdinah Bierke, arrived during visit at approximately 12:40PM. Facility provides care and assistance for older adults. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity and fire clearance for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 6 Residents in care and 3 staff members on-site.

At approximately 12:25PM, LPA reviewed the Facility's Staff Roster. Upon review, LPA observed that 2 of 3 staff members were not associated to the facility per regulation. LPA contacted the Santa Rosa Regional Office and confirmed the association status of the staff members. Facility sent the association paperwork for the two staff members to the Regional Office today, 04/29/2024. LPA confirmed with the Regional Office that the paperwork had been received. LPA discussed the importance of ensuring employee background clearance and association with Licensee/Administrator.

**Licensee/Administrator understands that a Civil Penalty is not being issued today for the two staff members because their association paperwork has been received by the Regional Office to be processed.**

At approximately 2:00PM, LPA conducted a walk-though of the facility and observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 5 resident bedrooms, 1 staff room, 3 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. 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. LPA and Licensee had a discussion regarding facility's water system. Facility recently had their boiler and water heater inspected January 2024 and had their boiler replaced.

Continued on LIC809C
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: COMFORTING HANDS FOREVER,LLC
FACILITY NUMBER: 216803245
VISIT DATE: 04/29/2024
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Continued from LIC809

Administrator's Certificate for Everdinah Bierke (6002749740) is currently pending. Review of Department of Social Services Administration Certification website indicated that the certificate renewal has been pending with payment received as of 06/20/2023.

Fire extinguishers were last inspected November 2023. Facility's last emergency drill was conducted February 2024.



LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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