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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803246
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:38:02 AM


Document Has Been Signed on 02/16/2023 11:38 AM - 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: 5DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elivra Gazal, LicenseeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced required 1-Yr. annual Infection Control inspection of this facility and met with Administrator Elvira Gazal. Currently there are 5 residents in care 2 are receiving hospice care and 4 residents with dementia diagnosis in care.

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 110.6 degrees F and 113 degrees F which is within regulation between 105 and 120 degrees F at bathroom faucets accessible to residents in care. 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 1/6/2023. Smoke detectors and Carbon Monoxide detectors were tested and found to be in working order. Facility has fire pull station located by front door. Medication is centrally stored and secure in kitchen along with small refrigerator with lock for medication (hospice kit). Disaster Drills had been conducted every 3 months the last being 2/1/2023.

Infection Control:

Facility has submitted a mitigation program plan and infection control plan. 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.



Continued LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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: 02/16/2023
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LPA reviewed Licensing Information System (LIS) with Licensee who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1st Aid certification for staff.
Administrator Certificate is for Elvira Gazal # 6008643740 Exp. 1/12/2024
All staff have received COVID booster vaccinations and inclusively work at this facility.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 2/28/2023 to SRRO:

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

Liability Insurance

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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