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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803246
Report Date: 07/28/2022
Date Signed: 07/28/2022 12:19:38 PM

Document Has Been Signed on 07/28/2022 12:19 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:
07/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee, Elvira GazalTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an investigation and follow up on an incident report received 07/25/2022 regarding an incident that occurred on 07/23/2022. LPA met with Administrator Elvira Gazal.

Based on the incident report submitted on 7/25/22 the resident (R1) left the facility through the front door after a visitor left the door ajar, not fully closing it, allowing the door alarm not to reset enabling R1 to leave the facility unassisted and without staff knowledge. A search was conducted by law enforcement and the resident was found nearby unharmed.
While conducting facility inspection LPA observed bedroom #2 sliding glass door open with alarm unconnected. LPA viewed with Licensee who made appointment to have door fixed today.

LPA reviewed documents which state that resident's (R1) condition restricts leaving the facility unassisted.

An immediate $500 Civil Penalty was assessed on 7/28/22 for absence of supervision.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

Plan of Corrections discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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Document Has Been Signed on 07/28/2022 12:19 PM - It Cannot Be Edited


Created By: Shannan Hansen On 07/28/2022 at 07:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A LOVING TOUCH CARE HOME II
FACILITY NUMBER: 216803246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited
HSC
1569.312(d)

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1569.312(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by:
Based on interviews conducted, the Licensee did not comply with the section cited above and did not ensure that staff knew the general
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Licensee to make needed repairs to secure entry & side bedroom #2 door of facility. Email of scheduled training due to CCL by 7/29/2022. Refresher training on Dementia Care with an emphasis on behaviors such as wandering is scheduled for all staff and Inservice training sign-in sheet will be sent to CCL by POC date of 08/04/2022.
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whereabouts of R1. It was reported that R1 left the facility unassisted and without staff knowledge. A search was conducted and R1 was found unharmed. This poses an immediate risk to the health and safety of residents in care.
An immediate $500 Civil Penalty was assessed on 7/28/22 for absense of supervision.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


LIC809 (FAS) - (06/04)
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