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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803992
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:15:57 PM

Document Has Been Signed on 11/02/2021 03:15 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GENTLE HOME CARE LLCFACILITY NUMBER:
216803992
ADMINISTRATOR:GHEZZEHAI, MARTHAFACILITY TYPE:
740
ADDRESS:463 NOVA ALBION WAYTELEPHONE:
(415) 499-1632
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
11/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Tigist DinkaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Gentle Home Care LLC for the purpose of conducting a Pre licensing inspection. LPA met with the Licensee, Tigist Dinka and was granted access into the facility.

LPA toured the facility with Licensee, Tigist Dinka. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices that were working properly during the visit. Fire Extinguisher was found to be last charged on 02/2021 at the time of the inspection. Smoke detectors and carbon monoxide detectors were found to be operational during the inspection. Hot water temperature measured between Title 22 acceptable regulation of 105 to 120 degrees while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and non-perishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the garage. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Facility has mattress pads available for residents as required by Title 22 Regulations # 87307 during today’s inspection. LPA conducted Component 3 during inspection, licensee was knowledgeable and had understanding of the regulations reviewed.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage. Facility is N95 Fit tested on September 8, 2021. Disaster drills were conducted in October 2021. No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Licensee, Tigist Dinka
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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