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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803847
Report Date: 06/23/2022
Date Signed: 06/23/2022 01:10:03 PM

Document Has Been Signed on 06/23/2022 01:10 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
06/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Samuel PadamaTIME COMPLETED:
01:22 PM
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Licensing Program Analyst (LPA) Walters arrived unannounced to follow up on a lack of communication from facility and to guide the facility on a possible eviction. LPA was greeted by staff, Administrator, Samual Padama arrived later.

During file review LPA learned of three incidents that were not reported to licensing involving resident's R1, R2 and R3. LPA reviewed incident report logs that confirmed that facility has not reported incidents to CCL within regulations.

LPA observed a single pill in a box, per staff S1 the pill belonged to R4, who refused to take their PM medication on 6/22/22. LPA checked R4 medication log (MAR), the MAR indicated that S1 gave R4 their medication when they did not. S1 stated that when R4 refuses medication at night, they wait until the morning after to give them their medication. Per Administrator and S1, it is common for R4 to refuse their medication. LPA discussed with Administrator and staff ways to respond when a resident refuses medication which may include: documenting, notifying responsible parties, physician, and licensing when a resident refuses.

LPA also observed a rope tied around 1 of the 2 facility exits preventing anyone from exiting. The facility was previously cited on 8/11/22 for obstructing a facility EXIT. (pictures taken). Administrator immediately removed.

An immediate civil penalty for $1000.00 was issued today for obstructing one facility EXIT. 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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/23/2022 01:10 PM - It Cannot Be Edited


Created By: Katrina Walters On 06/23/2022 at 12:09 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: L & S GENTLE CARE
FACILITY NUMBER: 486803847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2022
Section Cited
CCR
87203

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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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Licensee to ensure all exits are free from obstruction and are accessible at all times. Administrator to provide self-certification that they have read and understand regulation by POC due date 6/27/22.
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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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Type A
07/07/2022
Section Cited
CCR87465(a)(4)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:4) The licensee shall assist residents with self-administered medications as needed
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Administrator will provide staff with additional medication training. Administrator will document time, topics and participants in the training by POC due date 07/07/22
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This requirement was not met, when facility 1 of 4 residents, when staff did not provide resident medcation as prescribed by their physcian, which poses an immediate health and safety concern.
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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: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2022 01:10 PM - It Cannot Be Edited


Created By: Katrina Walters On 06/23/2022 at 12:38 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: L & S GENTLE CARE
FACILITY NUMBER: 486803847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
CCR
87211(b)

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87211 Reporting Requirements:
(a) Each licensee shall furnish...:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(B) Any serious injury...occurring while the resident is under facility supervision. This requirement was not met as evidenced by:
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Administrator to submit a written statement that they understand the regulation 87211(a)(1)(B) and provide incident reports that have not been reported to Licensing by POC due date 7/7/22.
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Based on record review and interviews conducted: Administrator did not ensure ensure incidents involving R1, R2 and R3 were reported to Community Care Licensing, which poses a potential health and saftey concern to resident in care.
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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: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


LIC809 (FAS) - (06/04)
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