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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803246
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:49:46 PM


Document Has Been Signed on 08/11/2022 01:49 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 IIFACILITY NUMBER:
216803246
ADMINISTRATOR:GAZAL, ELVIRA D.FACILITY TYPE:
740
ADDRESS:310 GOLDEN HIND PASSAGETELEPHONE:
(415) 891-8083
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:6CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Elvira GazalTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Licensee/Administrator Elvira Gazal. The purpose of this case management inspection is to follow up on a visit conducted on 7/28/2022 regarding an an incident of AWOL (7/23/2022) resulting in civil penalties.

LPA arrived at facility and conducted an inspection of the grounds. LPA observed sliding glass door to bedroom #2 able to lock and alarm to door functioning. Front door and all other exits observed to have functioning locks on doors and alarms. LPA assisted Licensee on the transfer association of a soon to be new staff. Live music is preformed at facility once every week and licensee informers residents families so they may join. The live music was playing while LPA conducted visit.

LPA obtained LIC 500 from licensee showing 3 additional staff along with Licensee. Facility has 6 residents of which 5 have dementia, 3 are two person assist, and 2 are on hospice.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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