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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 06/28/2022
Date Signed: 06/28/2022 02:38:55 PM

Document Has Been Signed on 06/28/2022 02:38 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:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Imelda Padama, LicenseeTIME COMPLETED:
02:49 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Imelda Padama, Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA toured the facility and observed 6 residents in care. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). LPA reviewed records and conducted a spot check of resident medication. Fire extinguisher was charged and and serviced 03/15/2022. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings; grab bars, non-slip mat, liquid hand soap and paper towels available in bathrooms. During this visit, LPA verified staff vaccination records for COVID-19.

LPA discussed the following requirements with Imelda Padama:
    · Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement) - Technical Advisory Note was issued to the facility during this visit.

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/13/2022:
1) LIC 308 Designation of Facility Responsibility (1 person per form); 2) LIC 500 Personnel Report; 3) LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents); 4) Copy of Liability Insurance; 5) LIC 610E Emergency Disaster Plan; 6) LIC 9020 Register of Facility Residents; 7) Copy of current Administrator's Certificate; 8) Copy of current Lease/Rental Agreement or Property Tax document showing control of property;
Reminder: Facility Infection Control Plan due 06/30/2022
Report continued on LIC 809-D...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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: 06/28/2022
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LPA observed R1 who requires oxygen administration and requested S1 to turn off and remove oxygen being administered. This is a restricted health condition. Per regulation:
      87618 Oxygen Administration - Gas and Liquid
      (a)Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances: (1) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself. OR (2) If intermittent oxygen administration is performed by an appropriately skilled professional.
During inspection dated 06/02/2022, LPA observed R1 receiving oxygen administration and R1 stated they are unable to independently operate the equipment. Licensee stated facility staff assist R1 with their oxygen and R1's Home Health comes to the facility 2 times per week. LPA stated the facility staff must have an appropriately skilled professional assist R1 per regulation. R1's LIC 602 indicates R1 requires assistance to administer oxygen. Facility to request an exception for R1 from Community Care Licensing. LPA will review and return to issue citations if warranted regarding R1.

The following deficiencies are being addressed during this inspection:
    · Reporting Requirements: During inspection dated 06/02/2022 LPA reminded facility and requested an Incident Report to be submitted for Resident (R1)'s hospital visit dated 05/24/2022. Licensee stated they would submit to CCL, but as of today's inspection CCL has not received it. The facility was previously cited for reporting requirements on 06/02/2022 *
    · Incidental Medical: During inspection of resident's medications on 06/28/2022, it was revealed staff crush resident (R2)'s medication. The facility does not have an order from R2's medical physician to crush medication.

Appeal Rights Provided. * a Civil Penalty was issued in the amount of $250 for a repeat violation
Deficiencies cited (see LIC809-D pages) 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: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2022 02:38 PM - It Cannot Be Edited


Created By: Karina Canela On 06/28/2022 at 12:57 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: 06/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2022
Section Cited

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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical…(5)…Assistance with self-administered medications...(D)...does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent
This requirement was not met as evidenced by:
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Based on interview and record review, the licensee did not comply with the section above due to R2 being given their medication crushed up, but does not have a crush order from the doctor (licensee stated R1 spits the pill out) which is an immediate health, safety or personal rights risk to persons in care
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Administrator to have all staff trained on regulation 87465 and submit medication training documentation (with date, time, duration, subject, attendee's names and signatures) to Community Care Licensing (CCL) by 07/13/2022 attention LPA Karina Canela
Type B
07/13/2022
Section Cited

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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:
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Based on record review and interviews conducted: Administrator did not ensure ensure the section above due to not notifying CCL of R1's hospital visit and Restricted health condition (oxygen administraton) as required. This is a potential health, safety and personal rights risk to the residents in care.
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***A civil penalty was assessed today in the amount of $250 for a repeat 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: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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