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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601149
Report Date: 05/09/2023
Date Signed: 05/09/2023 05:10:22 PM


Document Has Been Signed on 05/09/2023 05:10 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:GENTLE HANDS SENIORSFACILITY NUMBER:
385601149
ADMINISTRATOR:BANGURA, FATMATAFACILITY TYPE:
740
ADDRESS:2447 19TH AVENUETELEPHONE:
(415) 564-6695
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:6CENSUS: 5DATE:
05/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Fatmata BanguraTIME COMPLETED:
11:40 AM
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On 5/9/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Pre-Licensing visit. LPA met with Administrator, Fatmata Bangura and explained the purpose of the visit.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed the indoor and the outdoor passageways are free of obstruction. This is a single level facility with 7 bedrooms (6 private bedrooms for residents and 1 for staff), 2 bath/shower rooms. LPA toured the facility with the Administrator and observed the bedrooms are spacious, bright and cleaned. All bedrooms contained the required furniture and lighting requirements per CCLD regulations. Medication cabinet is locked and inaccessible to residents.

LPA inspected the kitchen and dining room area. Trash cans are observed to have foot operated lids. Dining room area is observed to be clean and in order. Chairs are in place. Both fresh food and frozen food supplies are inspected and observed to be sufficient, Dry goods/emergency food supplies are present. All required facility postings are posted.

Bathrooms were observed to be equipped with paper towels, hand-washing signs, liquid soap, and trash cans. Shower room is observed to have grab bars, non- skid mats and shower chairs. Water temperature throughout the facility was measured between 111- 113 degrees F. Facility is maintained at a comfortable temperature- 73 degrees F. Smoke detectors, fire alarms, and carbon monoxide systems are operating properly. COVID-19 signs are posted throughout the facility. Extra linen is stored in resident rooms. Chemicals is observed to be locked and inaccessible to residents.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GENTLE HANDS SENIORS
FACILITY NUMBER: 385601149
VISIT DATE: 05/09/2023
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Facility is clean and in good repair during today's inspection. Facility is in compliance with Title 22 regulations. No citations are issued.

Immediate licensure is recommended, pending final approval by Centralized Applications Unit.

Component III is conducted.

This report is reviewed with Administrator.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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