216803246-3-11-2022-21-AS-SHAN-CCESW2-20220311131337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803246
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:13:43 PM

Document Has Been Signed on 03/11/2022 01:13 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:	A LOVING TOUCH CARE HOME II		FACILITY NUMBER:	216803246
ADMINISTRATOR:	GAZAL, ELVIRA D.		FACILITY TYPE:	740
ADDRESS:	310 GOLDEN HIND PASSAGE		TELEPHONE:	(415) 891-8083
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	6	CENSUS: 5	DATE:	03/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Elvira Gazal, Administrator		TIME COMPLETED:	01:13 PM

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Licensing Program Analyst (LPA) Hansen conducted an unannounced required 1-Yr. annual Infection Control inspection of this facility and was greeted by Staff Marilyn Montero who called Administrator. Administrator Elvira Gazal arrived at the facility 15 minutes later. Currently there are 5 residents in care 2 are receiving hospice care and 4 residents with dementia diagnosis in care.

Today's inspection LPA observed 2 staff on shift. LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. Some residents have call buttons which sound in kitchen area. The amount of fresh and nonperishable foods is within regulation. Toxins are stored in locked garage and locked hallway closet. Water temperature measured at 110.4 degrees F which is within regulation between 105 and 120 degrees F at faucets accessible to residents. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguisher inspected was charged and dated 1/31/2022. Smoke detectors were tested and found to be in working order. Facility has fire pull station located by front door. Carbon Monoxide detector was present. Medication is centrally stored and secure in kitchen along with small refrigerator with lock for medication (hospice kit).

Infection Control:

Facility has submitted a mitigation program plan that was approved on 07/14/2021. In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available telephone calls when contacting with family members and others. Staff had all PPE training required on file and have received N-95 fit testing. All staff have received their COVID -19 Booster shots.

Continued LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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

LIC809 (FAS) - (06/04)

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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: A LOVING TOUCH CARE HOME II	FACILITY NUMBER: 216803246
	VISIT DATE: 03/11/2022

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In addition, LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills had been conducted every 3 months the last being 2/1/2022.

LPA reviewed Licensing Information System (LIS) with designee who stated request for mailing address submitted to CCL last week. Requesting all mail for facility & licensee be changed to facility address, 45 Meriam Dr, San Rafael they no longer reside at.

LPA viewed Administrator Certificate for Elvira Gazal #6008643740 Exp. 1/12/2024.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/31/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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