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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 07/09/2021
Date Signed: 07/14/2021 01:52:41 PM

Document Has Been Signed on 07/14/2021 01:52 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:L & S GENTLE CARE IIFACILITY NUMBER:
486803974
ADMINISTRATOR:PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:778 APPALOOSA CTTELEPHONE:
(707) 846-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
07/09/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Samuel Padama, ApplicantTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPAs) Karina Canela and Jill Nakagawa conducted a pre-licensing inspection on 07/09/2021. LPAs met with Applicants Samuel and Imelda Padama, who will be the Administrator when the facility is approved for licensure. The facility has a dementia care plan and has submitted a hospice waiver request for 2 residents. The facility has a fire clearance approval from the Fairfield Fire Department for 6 ambulatory residents for a total capacity of 6. Applicant stated they will request an updated fire clearance for 6 non-ambulatory residents. Facility will operate with a 24 hour staffing and Licensee will ensure sufficient staffing at all times.
During today’s visit LPAs observed the following items:
· COVID-19 postings and screening station at entrance
· Lockable separate cabinets for medications, toxin, and knives.
· All exits were unobstructed
· 7 smoke detectors, 1 combination smoke and carbon monoxide detector and 1 carbon monoxide detector, which were tested and observed to be operational
· First Aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip mats in 2 of 2 bathrooms.
· Fire Extinguisher charged
· Required furnishings in 2 of 6 resident bedrooms
· A shed in the backyard used for storage
· Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy).

Report continued on LIC 809-C.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: L & S GENTLE CARE II
FACILITY NUMBER: 486803974
VISIT DATE: 07/09/2021
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During today’s visit LPAs observed the following items:
· Chest of drawer needed in bedrooms 3, 4, 5, and 6. Applicant stated they would purchase 4 chest of drawers a minimum of 8 cubic feet per regulation and would send pictures as proof to LPA.
· 1 charged fire extinguisher without a service tag. Applicant stated it was a new purchase and would send a copy of the receipt.


Pre-licensing is incomplete with corrections needed for the following items to proceed with licensure.

· Required furnishings


· Receipt for purchase of new fire extinguisher


The Component III Orientation was completed during today's inspection.

Pre-Licensing is incomplete with above items to be resolved by 7/12/2021. Applicant to submit pictures as proof of correction to Community Care Licensing Department (CCLD) for review. Once corrections are submitted and reviewed by CCLD, LPA will submit the pre-licensing report with proof of corrections to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC809 (FAS) - (06/04)
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