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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 05/23/2022
Date Signed: 05/23/2022 02:46:42 PM

Document Has Been Signed on 05/23/2022 02:46 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 CARE IIFACILITY NUMBER:
486803974
ADMINISTRATOR:PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:778 APPALOOSA CTTELEPHONE:
(707) 846-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
05/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Imelda Padama, LicenseeTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at L & S Gentle Care II on 05/23/2022 for the purpose of addressing a deficiency. LPA met with Individual (I1); Sam Padama, Licensee and Administrator; Imelda Padama, licensee arrived later.

Fire Clearance Violation:
On 05/13/2021, 778 Appaloosa Ct Fairfield CA, 94533 (Prior to being licensed) was approved for six (6) ambulatory (total capacity 6) from the Fairfield Fire Department.

On 07/09/2021, LPA conducted the facility pre-licensing inspection during which LPA advised the licensee to request a fire clearance inspection for approval to accept and retain non-ambulatory and/or bedridden residents. Licensee Samuel Padama requested from Community Care Licensing (CCL) approval for four (4) non-ambulatory and two (2) bedridden for a total capacity of six (6) from the Fairfield Fire Department. The request was sent to the Fire Dept. on 07/21/2021. Licensee later notified CCL on 10/05/2021 that the fire clearance inspection was not scheduled yet and Licensee attempted to schedule it.

On 02/28/2022, LPA observed residents with an ambulatory status of non-ambulatory and bedridden in care at L & S Gentle Care II. LPA requested the facility immediately request a fire clearance request for non-ambulatory and bedridden ambulatory status.

On 03/22/2022, a fire clearance request was resubmitted for four (4) non-ambulatory and two (2) bedridden for a total capacity of six (6) from the Fairfield Fire Department.
Report continued on LIC809-C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: L & S GENTLE CARE II
FACILITY NUMBER: 486803974
VISIT DATE: 05/23/2022
NARRATIVE
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On 04/05/2022, LPA inquired with Licensee Sam Padama after the outcome status of the fire clearance request. Sam stated he decided not to go through with the request for the updated fire clearance because he no longer wanted to continue with the request for bedridden because the facility would need to install a fire door in the hallway to the residents room and it is narrow; Sam did not agree and had safety concerns.

On 04/06/2022, LPA sent Licensee an email warning with a copy of the facility license highlighted showing they are only approved for only 6 Ambulatory and regulation 87204 Limitations - Capacity and Ambulatory Status: 87204(b) "Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents."
LPA stated the facility needed to immediately request approval to accept and retain non-ambulatory residents since the facility had non-ambulatory residents in care without the proper fire clearance approval, to avoid a civil penalty and citation.
On 04/12/2022, a fire clearance inspection was requested for six (6) non-ambulatory (for a total capacity of 6)

On 05/17/2022, LPA verified with the Fairfield Fire Department that L & S Gentle Care II was not approved to accept or retain non-ambulatory residents. LPA was notified that Licensee Sam Padama declined to continue with fire clearance approval for non-ambulatory ambulatory status. Fire Inspector stated Licensee backed out of the fire clearance request about 2-3 weeks ago and instructed licensee to notify CCL.

On 05/19/2022, Licensee explained over the phone that they no longer wanted to continue with requesting approval for non-ambulatory clearance due to disagreeing with the fire department's requirements such as installing a fire protected door in the bedroom hallway since the hallway is "too narrow" and Licensee was unsure resident's wheelchairs would be able to safely fit through the hallway if a fire door was installed.
*LPA reiterated the warning sent on 04/06/2022 and that the facility is required to comply with the local Fire Department's requirements in order to accept or retain non-ambulatory (and/or bedridden) residents.
Licensee stated he would contact the fire department to schedule another fire clearance inspection.

*** As of 05/23/2022, the facility has 4 residents in care (R1 - R4) with a non-ambulatory status and 2 residents (R5 & R6) with diagnosis of Dementia (with ambulatory status). LPA requested the facility have R5 & R6 re-evaluated to confirm their ambulatory status and consider their mental condition.

Report continued on LIC 809-C..
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: L & S GENTLE CARE II
FACILITY NUMBER: 486803974
VISIT DATE: 05/23/2022
NARRATIVE
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Non-Associated Individual Violation:
Additionally during today's inspection, LPA observed Individual (I1) working and providing care to residents in the facility. It was revealed I1 had begun working at the facility since 05/01/2022.
LPA confirmed with the facility's personnel roster printed 05/23/2022 that I1 is not associated to L & S Gentle Care II. LPA confirmed with Community Care Licensing on 05/23/2022 through Guardian, that I1 is finger print cleared but not associated as required. (*LPA sent Licensee a copy of their facility staff roster on 04/28/2022 via email with a list of associated staff, I1 was not on the list.)
Licensee Sam Padama arrived later and stated I1 is fingerprint cleared and associated to sister facility L & S Gentle Care (located in Vacaville, CA). Licensee stated their office has had difficulty associating I1 and I1 was re-fingerprinted on 05/02/2022.
LPA explained prior to anyone working (including waiting for association, shadowing a staff and/or training), volunteering, residing or being present in any part of the licensed facility, they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation.
* LPA provided the forms to associate individual (I1) to licensee Imelda Padama during this inspection.
Licensee stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at a licensed facility, the individual must obtain a fingerprint clearance and be associated to the facility.

Dementia Program Care Plan Violation:
During today's inspection, LPA verified with the facility's file and Licensee that the facility does not have approval for a Dementia Program Care Plan and does not have one on file. Licensee stated they originally submitted a Dementia Care Plan with their application, however he notified the Centralized Application Bureau that the Licensee no longer wanted to continue with approval for a Dementia Program Care Plan since they would not accept or retain residents with a diagnosis of dementia. Licensee explained the facility planned to accept only residents with Mild Cognitive Impairment (MCI).

LPA verified on 05/23/2022 that R4, R5, & R6 have a diagnosis of Dementia.

LPA provided a copy of regulation 87705 Care of Persons with Dementia - 87705(c)(1)


Report continued on LIC809 - C..
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: L & S GENTLE CARE II
FACILITY NUMBER: 486803974
VISIT DATE: 05/23/2022
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Immediate Civil Penalties in the total amount of $1,250 were assessed today:
  • $500 for a fire clearance violation.
  • $500 for an non-associated individual.
  • $250 for a repeated violation of an non-associated individual present at the facility.



Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Licensee Imelda Padama, whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2022 02:46 PM - It Cannot Be Edited


Created By: Karina Canela On 05/23/2022 at 01:07 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 II
FACILITY NUMBER: 486803974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2022
Section Cited
CCR
87202(a)(1)

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87202 Fire Clearance:(a) All facilities shall ...Prior to accepting or retaining any of the following types of persons...obtain an appropriate fire clearance approved by the city...fire department...(1) Nonambulatory persons. This requirement was not met as evidenced by:
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Administrator to submit a statement that they understand the regulation and shall be in future compliance. Administrator to request a fire clearance inspection for non-ambulatory and/or bedridden from CCL and submit the required documents by POC due date 05/24/2022 to CCL
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Based on observation, interviews, and record review - Administrator did not ensure the regulation above due to having 4 non-ambulatory residents (R1-R4) in bedrooms that are not approved for non-ambulatory residents. This is an immediate health & safety risk to residents in care.
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*** An immediate Civil Penalty in the amount of $500 was assessed.
Type B
05/24/2022
Section Cited
CCR87355(e)(2)

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87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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Administrator to associate I1 as required. Administrator to submit a written statement they understand the requirement and will be in future compliance with the regulation by POC due date 05/24/2022 to Community Care Licensing
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Based on record review, observation, and interviews conducted: Administrator did not associate individual (I1) prior to working, residing or being present in the facility.
This is a potential safety and personal rights risk to the residents in care.
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**Civil Penalties assessed in the amount of $500.00 for non-associated individual working
and $250 for repeated violation
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:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022


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Document Has Been Signed on 05/23/2022 02:46 PM - It Cannot Be Edited


Created By: Karina Canela On 05/23/2022 at 01:31 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 II
FACILITY NUMBER: 486803974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2022
Section Cited
CCR
87208(c)

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87208 Plan of Operation:
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by:
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Administrator to submit a statement that they understand the regulation, will be in compliance, and not accept any additonal residents with diagnosis of dementia. Administrator to submit their a copy of their dementia program plan for their facility file. POC due date 05/27/2022 by close of business, 5 PM.
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Based on record review, observation, and interviews conducted: Administrator did not ensure the regulation above due to not having an approved dementia program care plan prior to accepting and retaining residents with a diagnosis of dementia.
This is a potential safety and personal rights risk to the residents in care.
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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:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022


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