<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803974
Report Date: 06/02/2022
Date Signed: 06/02/2022 05:46:55 PM

Substantiated


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
02/28/2022 and conducted by Evaluator Karina Canela
COMPLAINT CONTROL NUMBER: 21-AS-20220228080816
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:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Imelda Padama, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to provide adequate supervision resulting in resident sustaining pressure injuries

Staff did not follow resident's care plan

Staff did not inform resident's authorized representative of resident injuries

Staff failed to seek timely medical
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) K. Canela arrived at L & S Gentle Care II for the purpose of delivering findings on complaint # 21-AS-20220228080816. LPA met with Imelda Padama, Licensee.

LPA investigated the above allegations. During the investigation, LPA conducted interviews, reviewed the facility file, inspected the facility, obtained and reviewed records.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 21-AS-20220228080816
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 II
FACILITY NUMBER: 486803974
VISIT DATE: 06/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff failed to provide adequate supervision resulting in resident sustaining pressure injuries:
It was reported to Community Care Licensing that on 02/28/2022 the facility notified Resident (R1)’s responsible party of pressure injuries on R1’s feet. On 02/24/2022 Home Health indicated R1 developed: one stage III pressure injury, one un-stageable deep tissue injury and one intact blister. Interviews conducted revealed, R1’s wounds were quite deep and were likely not to have developed within one or two days, staff should have observed the initial start of the wounds if they had provided adequate supervision. In addition, interviews with relevant parties indicated such injuries would not have resulted on R1, if staff were to have given R1 proper body positioning.
As a result of resident (R1)'s injury, the violation warrants a civil penalty assessment based on Health & Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.
Allegation: Staff did not follow resident's care plan:
Review of facility records revealed a lack of required documentation to ensure R1’s care plan to meet their needs. Administrator did not do a proper pre-assessment of R1 prior to admitting R1 to L & S Gentle Care II. R1 is a 2-3 person assist and the facility did not have the proper fire clearance approval to admit or retain R1 due to their ambulatory status.
Allegation: Staff did not inform resident's authorized representative of resident injuries:
It was reported staff did not inform resident (R1)'s authorized representative of an incident. The unreported incident resulted in R1 sustaining a contusion on their lip and resulted in R1 needing oral surgery. Interviews with relevant parties indicated R1's lip contusion resulted from a fall or direct hit to R1's mouth. Staff interviews stated they were unaware if R1 sustained any falls or direct hit to R1's face that resulted in a contusion and oral surgery.
Staff failed to seek timely medical:
It was reported staff did not seek timely medical attention after R1 sustained an injury resulting in a contusion on their lip and oral surgery. Staff statements indicate they did not witness if R1 fell or that they were hit on the mouth. Interviews with relevant parties indicated R1's lip contusion resulted from a fall or direct hit to R1's mouth. R1's medical records indicate R1 was non-ambulatory at the time, was not able to walk independently and requires a 2-3 person assist. Staff statements indicated they notified R1's representative when R1 was found chewing on one of their teeth. Staff statements indicated they believed R1's tooth "just fell out" on its own. Staff then notified R1's representative, however staff did not seek medical assistance for R1's contusion.
Report continued on LIC9099-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20220228080816
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 II
FACILITY NUMBER: 486803974
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2022
Section Cited
CCR
87465(a)(2)
1
2
3
4
5
6
7
87456 Evaluation of Suitability for Admission: (a)Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall...(2) Perform a pre-admission appraisal.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator to submit a written statement that they understand the regulation 87465(a)(2) and shall be in future compliance.
Administrator to submit statement as the Plan of Correction (POC) by due date 06/08/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation
8
9
10
11
12
13
14
Based on record review and interviews conducted: Administrator did not ensure Resident (R1) was properly assessed with a pre-admission appraisal as required. This is a potential health, safety and personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type B
06/08/2022
Section Cited
CCR
87211(a)(1)(B)
1
2
3
4
5
6
7
87211 Reporting Requirements:
(a) Each licensee shall furnish...:(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...(B) Any serious injury...occurring while the resident is under facility supervision. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator to submit a written statement that they understand the regulation 87211(a)(1)(B) and shall be in future compliance.
Administrator to submit statement as the Plan of Correction (POC) by due date 06/08/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation
8
9
10
11
12
13
14
 Based on record review and interviews conducted: Administrator did not ensure ensure both R1's responsible person and Licensing were notified of R1's injury to mouth/teeth and pressure injuries within the timeframe as required. This is a potential health, safety and personal rights risk to the residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
02/28/2022 and conducted by Evaluator Karina Canela
COMPLAINT CONTROL NUMBER: 21-AS-20220228080816

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:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Imelda Padama, Licensee.TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff sleep during their work hours

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) K. Canela arrived at L & S Gentle Care II for the purpose of delivering findings on complaint # 21-AS-20220228080816. LPA met wit Imelda Padama, Licensee.
LPA investigated the above allegation. During the investigation, LPA conducted interviews, reviewed the facility file, inspected the facility, obtained and reviewed records. It was reported staff were observed sleeping on the couch during their work hours. Due to a lack of witnesses and corroborating statements, LPA was unable to prove or disprove the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Imelda Padama, Licensee, whose signature on this form confirms receipt of these documents.

No deficiencies cited regarding the above allegations during today’s visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20220228080816
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 II
FACILITY NUMBER: 486803974
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
§1569.269 Enumerated rights; severability: (a) Residents...shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff... to meet their needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator to submit a statement that they understand Health & Safety Code 1569.269(a)(6) and shall be in future compliance to meet the needs of residents in care.
Administrator to submit statement as the Plan of Correction (POC) by due date 06/03/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation
8
9
10
11
12
13
14
Based on record review and interviews conducted: Facility staff failed to ensure R1 received medical services in a timely manner after R1 sustained an injury to their mouth & pressure injuries (one stage 3). This is an immediate health, safety and personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type A
06/03/2022
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident : The licensee shall ensure that residents are regularly observed for changes in physical... functioning and that appropriate assistance is provided when such observation reveals unmet needs... (continued --->)
1
2
3
4
5
6
7
(continued) ...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person...This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on record review and interviews conducted: Facility staff failed to ensure proper care & supervision for R1 which resulted in R1 sustaining a stage 3 pressure injury. This is an immediate health, safety and personal rights risk to the residents in care.
8
9
10
11
12
13
14
Administrator to submit a statement that they understand regulation 87466 and shall be in future compliance ensuring residents are are regularly observed for changes.
Administrator to submit statement as the Plan of Correction (POC) by due date 06/03/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20220228080816
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 II
FACILITY NUMBER: 486803974
VISIT DATE: 06/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations were found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6), are being cited on the attached LIC 9099-D pages.

Appeal Rights Provided.


Deficiencies cited from the California Code of Regulations, (Title 22, Division 6) on the attached LIC9099-D pages. 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: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6