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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:37:05 PM

Document Has Been Signed on 01/09/2024 02:37 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
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:
01/09/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Samuel Padama, AdministratorTIME COMPLETED:
02:51 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver. Administrator Samuel Padama arrived at approximately 9:50am.

LPA discussed NCC concerns and found that the facility has submitted updated plan and facility sketch to City of Fairfield for building permit. Admin will provide CCL with all documents submitted to City of Fairfield for building permit. Fire extinguishers serviced 7/11/2023.

At approximately 10:00am Admin and LPA toured facility, LPA observed that the constructed bedroom in the garage is being used only for storage, LPA confirmed with Admin that staff are not sleeping in the common areas or in the garage. LPA observed the shed in the backyard to be locked and used only for storage. Per LPA interview with Admin there are no pre-poured medications. LPA measured water temperature: water temp measured 118.8 and 115.7, respectively which are both within regulation of 105 to 120 F.

Admin advised LPA that house managers have quit as of Friday, January 9, 2024. Admin informed LPA that they will take over the managers' duties. Admin to submit to CCL a written plan on how they plan to provide the services that the managers were providing. Admin will provide LPA with updated LIC500 showing Admin will be here a combined total of 20 hours per week, physically present on business days during business hours.

LPA conducted a record review of [4] out of [4] staff files. Staff files complete. Proof of respective required staff training present in respective staff files. LPA conducted review of [5] out of [5] resident files. All required documents present and complete. LPA advised Admin that they need to also call 911 and/or a resident's physician when appropriate, not just contact the resident's family. Admin confirmed they understand

No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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