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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803847
Report Date: 08/11/2021
Date Signed: 08/11/2021 06:23:46 PM

Document Has Been Signed on 08/11/2021 06:23 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:L & S GENTLE CAREFACILITY NUMBER:
486803847
ADMINISTRATOR:PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:162 N ALAMO DRIVETELEPHONE:
(707) 246-1100
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
08/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Samual Padama, AdministratorTIME COMPLETED:
06:35 PM
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Licensing Program Analysts (LPA) Katrina Walters arrived unannounced to conduct an Annual Required inspection and met with Lead Staff, , Elizabeth Manaois (EM). Administrator/Licensee Samual Padama 6050197740 exp 11/28/22 arrived later. LPA conducted a risk assessment with Staff prior to entering the facility. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. This facility has submitted a Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808), which was reviewed an approved by Community Care Licensing on 4/19/21.

Upon entry, LPA signed into the facility sign-in sheet, which included a list of screening questions. Hand sanitizer was also available. At the time of the inspection LPA observed that there were two staff providing care and supervision for 4 residents. 3 residents were socially distanced in the dinning room and 1 resident was in their bedroom with staff.

The facility was clean and a comfortable temperature. Per staff the facility is disinfected daily and after every meal. LPA observed that proper signage was posted throughout the facility to promote hand washing and socially distancing. Each resident has a designated visitation area. Facility has a 30-day supply of Personal Protective Equipment (PPE), medication, and incontinence care supplies for all residents.


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SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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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Document Has Been Signed on 08/11/2021 06:23 PM - It Cannot Be Edited


Created By: Katrina Walters On 08/11/2021 at 05:13 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: L & S GENTLE CARE
FACILITY NUMBER: 486803847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
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Based on Observation, Licensee did not comply by obstructing two facilty exits. which poses an immediate health, safety or personal rights risk to persons in care.**Immediate Civil Penalty assessed in the amount of $500.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: L & S GENTLE CARE
FACILITY NUMBER: 486803847
VISIT DATE: 08/11/2021
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Continued from 809

All staff are routinely trained on infection control and on how to don and doff PPE from Solano County Public Health. In addition all staff have been fit-tested.

Smoke detectors and Carbon Monoxide detectors were functioning properly. At 4:52 PM LPA observed that both facility Exit gates were obstructed with a rope and the other exit with a latch. LPA was unable to open either gate. (pictures taken.) Staff were present. Administrator immediately removed the rope and latch that were placed on the facility EXITs. Facility Administrator understands they will need to request and have fire department clearance and CCL approval before locking an EXIT.

An immediate civil penalty for $500.00 was issued today for obstructing two facility EXITs. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and or Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. This report was read and discussed with Administrator, Samual Padama. Appeal rights were provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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