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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803992
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:50:14 PM

Document Has Been Signed on 11/19/2024 02:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GENTLE HOME CARE LLCFACILITY NUMBER:
216803992
ADMINISTRATOR/
DIRECTOR:		GHEZZEHAI, MARTHAFACILITY TYPE:
740
ADDRESS:463 NOVA ALBION WAYTELEPHONE:
(415) 499-1632
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Staff Member, Tigist DinkaTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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At approximately 1:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Staff Member, Tigist Dinka. Administrator, Miriam Ghezzehai, was available by telephone. Facility is a Residential Home for the Elderly and provides care and assistance for Older Adults. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 6 residents in care, and 2 staff members on-site.

At approximately 1:20PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:25PM, LPA conducted a walk-though of the facility. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 6 Resident bedrooms, 4 bathrooms, a staff break room and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. During walkthrough, LPA observed the following to be unlocked and accessible to residents in care: clorox jug outside in the backyard, scissors in the cabinet of a resident bathroom, and multiple cleaning supplies underneath the kitchen sink (deficiency cited, LIC809D, regulation 87705(f)). LPA observed that the lock for the kitchen sink cabinet was broken. Staff Member immediately place all toxins in the garage. LPA also observed that all sinks accessible to residents were out of compliance with Title 22 Regulations, measuring at 131.1F, 134.4F, 123.0F, 121.8F, 120.9F, and 121.1F (deficiency cited, LIC809D, regulation 87303(e)(2)). Facility's fire extinguishers were last inspected February 2023. Facility's last fire drill was conducted October 2024.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GENTLE HOME CARE LLC
FACILITY NUMBER: 216803992
VISIT DATE: 11/19/2024
NARRATIVE
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Continued from LIC809

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Staff Member. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/19/2024 02:50 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/19/2024 at 02:16 PM
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: GENTLE HOME CARE LLC
FACILITY NUMBER: 216803992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure that the following items were stored inaccessible to residents with dementia: scissors in resident bathroom, cleaning supplies under kitchen sink, and clorox jug in the backyard. This poses an immediate health and safety risk to residents in care.
POC Due Date: 11/20/2024
Plan of Correction
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Licensee to submit self certification that Regulation will be reviewed for all staff and that a reminder notice will be posted in the facility. Certification and photograph proof of reminder notice to be submitted by POC Due Date of 11/20/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/19/2024 02:50 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/19/2024 at 02:23 PM
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: GENTLE HOME CARE LLC
FACILITY NUMBER: 216803992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, the Licensee did not comply with the section cited above. All facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring at 131.1F, 134.4F, 123.0F, 121.8F, 120.9F, and 121.1F. This poses a potential health and safety risk to residents in care.
POC Due Date: 12/02/2024
Plan of Correction
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Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks in each house starting on 11/20/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 12/02/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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