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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601149
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:29:27 PM

Document Has Been Signed on 05/09/2024 04:29 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GENTLE HANDS SENIORSFACILITY NUMBER:
385601149
ADMINISTRATOR/
DIRECTOR:		BANGURA, FATMATAFACILITY TYPE:
740
ADDRESS:2447 19TH AVENUETELEPHONE:
(415) 564-6695
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY: 6CENSUS: 6DATE:
05/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Aminata Jalloh and Anica Koljenik, Caregivers, and Fatmata Bangura, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On May 9, 2024 at 1:45 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the Annual 1-year required inspection started on March 26, 2024. LPA Calandra was greeted by Anica Koljenik, Caregiver and explained the purpose of the visit. Administrator/Licensee, Fatmata Bangura arrived later during the visit.

LPA Calandra reviewed 3 staff files. All were observed to be complete but missing the LIC 501: Personnel Record and LIC 503: Health Screening Reports.

LPA Calandra interviewed 2 residents and 2 staff.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day.

A Type B Violation was provided for not having a record of dosages of medications which are centrally stored at the facility.

A Type B Violation was provided for not having Health Screening Reports for staff.

Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report was reviewed with Fatmata Bangura, Administrator/Licensee and a copy of the report along with Appeal Rights left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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Document Has Been Signed on 05/09/2024 04:29 PM - It Cannot Be Edited


Created By: John Calandra On 05/09/2024 at 04:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GENTLE HANDS SENIORS
FACILITY NUMBER: 385601149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87412(a): Personnel Records: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 personnel records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87465(a)(6): Incidental Medical and Dental Care Services: Based on record review, the licensee did not comply with the section cited above in 4 out of 4 residents, who the facility did not have Centrally Stored Medication Records for, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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