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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 10/12/2023
Date Signed: 10/12/2023 11:46:05 AM

Document Has Been Signed on 10/12/2023 11:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 5DATE:
10/12/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Raamil Gilbert, CaregiverTIME COMPLETED:
12:15 PM
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On 10/12/2023 Licensing Program Analyst (LPA) Carol Fowler arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, Raamil Gilbert. House manager Imelda Garcia arrived at 10:36am.

LPA discussed NCC concerns and found that the facility has submitted updated plan for building permit and serviced fire extinguisher, service date 7/11/2023 to CCLD. LPA C. Fowler and House Manager Imelda Garcia toured the facility, LPA observed that the constructed bedroom in the garage is being used for storage, LPA was informed by House Manager that no staff is sleeping in the common areas. The shed in the backyard is locked and being used for storage. There are no pre-poured medications, water temperature is 119.6 within regulation of 105 to 120 F. LPA conducted a record review staff files have been updated with health screenings (TB tests) and current training's. R1, R3, R5 files have been updated, R4 has been discharged from the facility.


No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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