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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803847
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:40:29 PM

Document Has Been Signed on 11/07/2023 12:40 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:
11/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caregiver, Dominica BastoTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at L & S Gentle Care for the purpose of conducting a Plan of Correction (POC) visit. LPA was greeted at the door by Caregiver, Dominica Basto. LPA was granted access into the facility.

During the POC inspection, LPA observed the correct Medication Orders for two residents in care.

No deficiencies were observed or cited during this POC inspection. Exit interview was conducted and a copy of this report was signed and given to the Caregiver.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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