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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803992
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:38:27 AM

Document Has Been Signed on 10/19/2022 10:38 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: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:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Martha Ghezzehai, Administrator, via phoneTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection focusing on Infection Prevention Protocols.

LPA was met at the door by caregiver who was engaged with residents: some of whom were eating breakfast, some watching TV and the others were resting in bed. All residents were social and interactive and expressed their satisfaction of living in the homelike setting, which was clean and orderly. Each resident has a private room, and each room had all the required furnishings. The kitchen was clean and organized, and had the required food stores of both perishable and non-perishable foods. There was additional food storage in a garage, including a freezer of perishables and cupboards of dry foods. There was an ample supply of fresh fruits and vegetables. Toxins and cleaning supplies were locked in garage. Medications are stored and locked
in cabinet in dining room.

The facility has 2 fire extinguishers and a central fire alarm system which were last serviced on 02/02/2022. There were also 11 fire alarms and 2 carbon monoxide detectors which were operational at the time of inspection. The exterior doors were all alarmed and free from obstruction. The back yard was well-maintained and provided shade and plenty of places for the residents and guests to visit outside when social distancing is necessary.

The facility has Covid-19 and other signage posted throughout, reminding staff and residents about Cough Etiquette and Hand Washing. The staff are wearing masks and the facility has soap and paper towels at each sink, as well as hand sanitizer. All the residents have received their 2nd booster for Covid-19, and the staff are in the process of getting the residents their flu vaccines. Infection Control Plan submitted.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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