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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803992
Report Date: 06/09/2026
Date Signed: 06/09/2026 02:21:44 PM

Document Has Been Signed on 06/09/2026 02:21 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:
06/09/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Staff Member, Tigist DinkaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit, and met with Staff Member, Tigist Dinka. Administrator, Martha Ghezzehai, arrived during visit at approximately 1:50PM. The purpose of the visit was to follow up on a self-reported incident report that was submitted to the Santa Rosa Regional Office (SRRO).

Incident Report 1: The SRRO received a report on 12/22/2025. Report stated that on 12/19/2025, Resident 1 (R1) left the facility. Per report, the night-time caregiver was providing care to another resident when R1 left the facility. Facility notified San Rafael Police Department (SRPD) and Fire Department. R1 was found down the street from the facility by SRPD. R1 was sent to the hospital for further evaluation as it was observed R1 had a fall. Facility made all appropriate notifications per regulation.
Review of R1's medical assessment dated 10/05/2025 does not indicate if they have a diagnosis of dementia and stated they can to leave the facility unassisted. Review of R1's care plan dated 12/07/2025 indicated that R1 had a diagnosis of dementia. Review of R1's medical assessment dated 02/20/2026, states that R1 has a diagnosis of dementia and is unable to leave unassisted. There was no updated care plan to reflect R1's new medical assessment from February 2026. Review of documents showed that facility conducted elopement training on 12/20/2025.
LPA discussed with Administrator on ensuring that resident documents are filled out correctly and are updated to reflect their care needs as required. Per Administrator, R1 is scheduled for a new medical assessment at the end of the month. Administrator to submit updated paperwork to Community Care Licensing (CCL) as part of their plan of correction.

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 Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/09/2026 02:21 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 06/09/2026 at 12:17 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: 06/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2026
Section Cited
CCR
87705(e)(7)

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87705 Care of Persons with Dementia (e) Licensees that use delayed egress devices...
shall meet the following...requirements: (7) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents...this requirement was not met as
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Licensee provided proof of elopement training dated 12/20/2025 during visit. Licensee to update LPA on when R1's medical assessment is scheduled by POC due date of 06/19/2026. Licensee to submit proof of updated documents: LIC602/Physician's Report and LIC625/Care Plan
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evidenced by: based on record review, Licensee did not comply with the section cited above. Resident 1 (R1) eloped from the facility. R1's physician report showed they are unable to leave unassisted. This poses an potential health/safety/personal rights risk to residents in care.
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to CCL once received.

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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2026


LIC809 (FAS) - (06/04)
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