486803847-11-21-2023-21-AS-BMOS-CXTSZN-20231122131926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803847
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:05:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20231101142046

FACILITY NAME:	L & S GENTLE CARE		FACILITY NUMBER:	486803847
ADMINISTRATOR:	PADAMA, SAMUEL		FACILITY TYPE:	740
ADDRESS:	162 N ALAMO DRIVE		TELEPHONE:	(707) 246-1100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	6	CENSUS: 6	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Caregiver, Luzviminda Torress		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not ensure assistance was provided to resident in care
Staff was asleep while at work
Staff dispensed medication not as prescribed to resident in care
Staff financially abused resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at L & S Gentle Care for the purpose of delivering complaint findings. LPA was greeted at the door by Caregiver, Luzviminda Torress. LPA was granted access into the facility.

During the course of the investigation, LPA interviewed all residents in care and staff. In addition, LPA made observations of the Medication Administration Record (MAR) for Resident #1.

Complaint alleges that staff did not ensure assistance was provided to resident in care. Based on interviews that were conducted with residents and staff, LPA could not corroborate the allegation. In addition, there were inconsistent information during interviewing.

(Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231101142046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 486803847
	VISIT DATE: 11/21/2023

NARRATIVE

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However, during an observation of documents, LPA observed that a FaceTime still photo was taken that depicted a Personal Rights violation. LPA learned that the facility was made aware about this incident in early October 2023 and failed to report to the Department of Social Services-Community Care Licensing Division (See LIC 809-Case Management-Deficiencies dated for November 21, 2023).

Complaint alleges that staff was asleep while at work. Based on interviews that were conducted, LPA could not corroborate the allegation. Furthermore, LPA reviewed a photo that provided no additional details into the time, date and place that the alleged caregiver was sleeping. LPA observed the staff schedule for the alleged caregiver, and learned that the alleged caregiver does not work night shift at the facility.

Complaint alleges that Staff dispensed medication not as prescribed to resident in care. Based on interviews conducted and observation, LPA could not corroborate the allegation. Furthermore, LPA reviewed the Medication Administration Record (MAR) for Resident #1 on November 7, 2023 and found no concerns during the MAR review.

Complaint alleges that Staff financially abused resident in care. Based on interviews that were conducted, LPA could not corroborate the allegation. Residents were interviewed which yielded no additional supporting information. Furthermore, LPA received inconsistent statements during interviewing.

A finding that the complaint allegation of Staff did not ensure assistance was provided to resident in care, Staff was asleep while at work, Staff dispensed medication not as prescribed to resident in care, Staff financially abused resident in care are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to Caregiver, Luzviminda Torress.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

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