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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803847
Report Date: 10/23/2023
Date Signed: 10/23/2023 03:29:43 PM

Document Has Been Signed on 10/23/2023 03:29 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
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: 6DATE:
10/23/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver, Sheila GeotinaTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at L & S Gentle Care for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Sheila Geotina. LPA was granted access into the facility.

During the Case Management-Annual Continuation, LPA reviewed medication orders for 6 of 6 residents in care. 2 out of 6 residents were missing medication that were supposed to be retained in the Medication Closet (See LIC 809D). LPA conducted resident file reviews and found that a 2 out of 6 residents that are diagnosed with Dementia did not have the required annual medical assessment as outlined in Title 22 regulations (See LIC 809D). The Infection Control Plan and the Emergency Disaster Plan were not reviewed due to the Administrator not being at the facility to review it (See LIC 9102's Technical Violations). LPA requested the following documents to be sent:

LIC 500-Personnel Report
LIC 308-Designation of Responsibility
Liability insurance
Control of Property
Resident Roster
Updated Infection Control Plan
Emergency Disaster Plan

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to Caregiver, Sheila Geotina.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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 10/23/2023 03:29 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/23/2023 at 02:06 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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on observation and medication record review, the licensee did not comply with the section cited above in 2 out of 6 residents were missing medication that were supposed to be retained in the Medication Closet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Plan of Correction shall include following up with the prescribing physician and/or pharmacy to fill the scripts. In additon, facility licensee shall submit a LIC 9098-self certification form and to submit a plan for future compliance.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2023 03:29 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/23/2023 at 02:58 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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 6 residents that are diagnosed with Dementia did not have the required annual medical assessment as outlined in Title 22 reguatlions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Plan of Correction shall include submitting a plan for future compliance and also reviewing ALL Medical Assessments to ensure that residents who are diagnosed with Dementia have had a annual medical assessment as outlined in Title 22 regulation. In addition, Licensee shall submit an LIC 9098-Self Certification understanding the regulation.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


LIC809 (FAS) - (06/04)
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