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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803974
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:19:16 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/17/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 21-AS-20231017145432
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:
10/20/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ramilgilbert Razon, CaregiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure assistance was provided to resident in care
Staff was asleep while at work
Staff dispensed medication not as prescribed to resident in care
Staff financially abused resident in care
INVESTIGATION FINDINGS:
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On 10/20/2023, Licensing Program Analyst, Carol Fowler arrived unannounced for the purpose of opening a 10-inital complaint investigation and delivering findings. LPA was greeted by Caregiver, Ramilgilbert Razon. LPA toured the facility with House Manager, conducted interview with resident (R1), Staff (S2, S3 & S4) LPA called S1 but was unsuccessful and unable to leave a voicemail. LPA received text messages and emails from RP. LPA conducted facility file/e-MAR review and made observations.

Complaint alleges: Staff did not ensure assistance was provided to resident in care. During a tour of the facility, LPA observed a staff member assisting a resident with ADL's and another staff assisting a resident to her chair after breakfast. Based on interviews with staff and resident that was conducted, LPA learned of no concerns regarding the care of residents in care. Therefore, the allegation is UNSUBSTANTIATED.

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 2
Control Number 21-AS-20231017145432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 486803974
VISIT DATE: 10/20/2023
NARRATIVE
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Continue from LIC9099

Complaint alleges: Staff was asleep while at work. LPA interviews with staff and resident revealed that there is no staff sleeping while on duty. House Manager Imelda Garcia stated that staff have breaks in the garage and on occasions leave the facility, S2 and S3 stated that staff take turns for breaks in the garage and for long breaks they leave the facility. Staff stated sleeping on the job is not expected of staff or allowed. Staff also stated that they have not observed staff sleeping on the job. Therefore, the allegation is UNSUBSTANTIATED.

Complaint alleges: Staff dispensed medication not as prescribed to resident in care. LPA conducted record review e-MAR and interviews with staff and resident which revealed that the facility has not had any medication errors or issues. Based on the medication record and physician's orders on file, residents have received their required medications. Therefore, the allegation is UNSUBSTANTIATED.

Complaint alleges: Staff financially abused resident in care. LPA interviewed staff and resident it is revealed that the facility is not responsible for residents finances. Interview conducted with resident (R1) revealed that staff has never asked R1 for money. Therefore, the allegation is UNSUBSTANTIATED.

Report was reviewed with House Manager Imelda Garcia and copy was provided.
No deficiencies cited during visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2