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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803245
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:02:36 PM


Document Has Been Signed on 02/24/2023 03:02 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
CCLD Regional Office, 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: DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Administrator, Ever BierkeTIME COMPLETED:
03:15 PM
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At approximately 1:05PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit, and met with Staff Member, Faye Canete. Administrator, Ever Bierke, arrived at approximately 1:30PM. The inspection visit is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA checked in at the front door. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Handwashing signs were observed in the bathrooms and at sinks. All staff and visitors were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a cleaning and disinfecting schedule that occurs daily. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. Facility checks Resident's temperatures weekly. Per their sign in log, LPA observed that facility used to check temperatures but have stopped. LPA and Administrator discussed continuing the COVID screenings until the State of Emergency for COVID is no longer in effect.

LPA and Administrator discussed the following:
  • Covid and Influenza A Protocols
  • Staffing Resources and Staff Training
  • Incident/Death Reports and Reporting Requirements
  • Annual Inspection Expectations

Facility has a plan in place if a staffing shortage were to occur. Facility has submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL).

Continued on LIC809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COMFORTING HANDS FOREVER,LLC
FACILITY NUMBER: 216803245
VISIT DATE: 02/24/2023
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Continued from LIC809

Fire extinguishers were last serviced October 2022. Smoke and Carbon Monoxide detectors were tested and operational.

LPA requested the following documents to update facility file:

Facility Documents
  • Administrative Organization (LIC 309)
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Current Administrator Certificate
  • Surety Bond (LIC 402)
  • Liability Insurance
  • Updated Register of Clients/Residents (LIC 9020)

Documents to be submitted to Community Care Licensing (CCL) by Friday, 3/24/2023.

No Deficiencies Cited during visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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