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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803847
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:06:47 PM

Document Has Been Signed on 11/21/2023 02:06 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:
11/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caregiver, Luzviminda TorressTIME COMPLETED:
02:15 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 Case Management-Deficiencies inspection. LPA was greeted at the door by Caregiver, Luzviminda Torress. LPA was granted access into the facility.

During the dates of November 7, 2023, November 17, 2023 and today, November 21, 2023, LPA observed that the Administrator and facility manager was not present and the only time that they made themselves available in-person was on November 17, 2023 (See LIC 9102-Technical Violation).

During the course of an investigation that was initiated on November 7, 2023, LPA observed/reviewed photos of a FaceTime still photo that was taken when the resident was getting changed which is a Personal Rights violation (See LIC 809D). LPA conducted an interview with the alleged Caregiver (See LIC 812-Interview-Caregiver #2 dated for November 17, 2023). During the interview on November 17, 2023 at approximately 11:21 AM, Caregiver acknowledged that it was her in the photo and alleged that "someone set her up, and that a former caregiver was up on the small table taking that photo." While conducting an additional interview with the Assistant Facility Manager, (See LIC 812-Interview-Assistant Facility Manager dated for November 17, 2023) 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 809D).

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, 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
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 11/21/2023 02:06 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 11/21/2023 at 01:29 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: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities:

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee shall submit a an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide Care and Supervision regarding Personal Rights.
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This requirement was not met as evidenced by:

Based on an observation/review, LPA observed/reviewed photos of a FaceTime still photo that was taken when the resident was getting changed which is an immediate health, safety and personal rights risk to the residents in care
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Plan of Correction due on November 27, 2023.
Type A
11/22/2023
Section Cited
CCR87211(a)(1)(d)

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87211 Reporting Requirements

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(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 any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Licensee shall submit a an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide Care and Supervision regarding Reporting Requirements.
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This requirement was not met as evidenced by:

LPA learned that the facility was made aware about the incident in early October 2023 and failed to report to the Department of Social Services-Community Care Licensing Division which presents an immediate health, safety and personal rights risk to the residents in care.
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Plan of Correction due on November 27, 2023.
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
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