216803246-3-5-2024-21-AS-SHAN-D33TDG-20240305133819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803246
Report Date: 03/05/2024
Date Signed: 03/05/2024 01:38:44 PM

Document Has Been Signed on 03/05/2024 01:38 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: 6	DATE:	03/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elvira Gazal, Licensee/Administrator		TIME COMPLETED:	02:00 PM

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Licensing Program Analysts (LPA’s) Shannan Hansen & Julie Florio conducted an unannounced required annual inspection of this facility and met with Licensee/Administrator Elvira Gazal. Facility has 6 residents in care, 1 receiving hospice care and 4 residents with dementia diagnosis.

At approximately 9:00 AM LPA’s toured the building and grounds with Licensee, which was found to be clean and in good repair. LPA's observed all walkways and exits to be unobstructed. Some residents have call buttons which sound in kitchen area. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in locked garage and locked hallway closet. Water temperature measured between 116.4 and 118.7 degrees F which is within regulation between 105 and 120 degrees F in 2 out of 2 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 last charged on 1/2/2024. Smoke detectors and Carbon Monoxide detector was tested and found to be in working order. Facility has fire pull station located by front door. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in kitchen along with small refrigerator with lock for medication.

Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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: 03/05/2024

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Continued from LIC809

At approximately 10:00 AM, LPA’s reviewed 6 of 6 resident records and found 6 of 6 residents have current physician’s reports or care plans. 6 of 6 resident records contained current and signed admission agreements and physician’s orders on file.

At approximately 11:20 AM, LPA’s reviewed 4 of 4 staff records. 4 of 4 records contain documentation of completed training records as required. Evidence of current first aid and CPR training were observed.

Medications were centrally stored in locked cabinet in the facility kitchen. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 3/5/2024 at approximately 1:00 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

At approximately 12:30 PM, LPA’s reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts quarterly disaster drills with the last disaster drill conducted on 2/1/2024. Elvira Gazel Administrator Certificate 6008643740 expired 1/12/2024 LPA observed pending certification received 10/23/2023. LPA reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time; no need to change any of the information.

No deficiencies cited during today’s inspection

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 3/25/2024:

LIC 308 Designation of Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changed)
LIC 9020 Register of Facility /Resident’s
Control of Property – Lease or Deed
Copy of Administrator’s 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: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC809 (FAS) - (06/04)

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