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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803847
Report Date: 10/11/2024
Date Signed: 10/11/2024 02:15:33 PM

Document Has Been Signed on 10/11/2024 02:15 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/
DIRECTOR:		PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:162 N ALAMO DRIVETELEPHONE:
(707) 246-1100
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 6DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Imelda Padama, Assistant Director TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On 10/11/2024, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Assistant Director Imelda Padama and explained the purpose of the visit. There were six (6) residents and two (2) caregivers at the time of inspection.

LPA Nakagawa and Assistant Director toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels and hand soap. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured within the required range. LPA observed 2 fire extinguishers, fire detectors, and carbon monoxide detectors throughout out the facility. LPA observed the first aid kit to be complete and ready for use.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and five (5) staff files which contained all the required documentation.

Several topics were discussed. LPA requested: LIC500, Proof of Liability Insurance

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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