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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 04/05/2024
Date Signed: 04/05/2024 11:45:33 AM

Document Has Been Signed on 04/05/2024 11:45 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/
DIRECTOR:		PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:778 APPALOOSA CTTELEPHONE:
(707) 846-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
04/05/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Chin Razon, facility designeeTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christi Coppo and LPA Julie Florio arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, facility designee (FD) was present at facility. Administrator Samual Padama was available via telephone.

On visit on 1/9/2024, LPA discussed NCC concerns and found that the facility has submitted updated plan and facility sketch to City of Fairfield for building permit. Admin provided CCL all documents submitted to City of Fairfield for building permit, LPA verified building permit work is still going on and Admin verified that they are still working to complete the job. Fire extinguishers serviced 7/11/2023.

At approximately 10:00am Admin and FD toured facility, LPA observed that the constructed bedroom in the garage is being used only for storage, LPA confirmed with Admin and FD that staff are not sleeping in the common areas or in the garage. LPA and FD observed the shed in the backyard to be locked and used only for storage. Per LPA interview with FD and Admin there are no pre-poured medications. Per FD they are not pre-pouring, but rather wait until it is time to administer residents' medications and bring them to a designated corner in the kitchen to minimize medication errors.

At last visit on 1/9/2024 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. After visit on 1/9/2024, Admin provided CCL with training records for caregiver that will help take care of some of the duties that the managers were taking care of; also, Admin provided 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 file for S1 did not have training records. Per Title 22 regulation 87411(c) Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (deficiency cited, see 809D).

Conituned on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/05/2024
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Continued from 809...

LPA conducted review of [5] out of [5] resident files. One resident (R1) with move in date of 3/27/2024 did not have an Appraisal Needs and Services Plan. LPA advised FD that all residents must have a preappraisal conducted before admission.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with FD and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2024 11:45 AM - It Cannot Be Edited


Created By: Christi Coppo On 04/05/2024 at 11:20 AM
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: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
87411(c)

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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...
This requirement is not met as evidenced by:
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Facility to submit LIC9098 self-certifying that S1 has compelted the annual training as required. Facility to submit training log or print out with LIC9098 by POC due date.
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Based on LPA and Admin observation staff memeber S1 did not have their annual training current or completed.
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024


LIC809 (FAS) - (06/04)
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