<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 07/17/2024
Date Signed: 07/17/2024 07:21:34 PM

Document Has Been Signed on 07/17/2024 07:21 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/
DIRECTOR:		PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:778 APPALOOSA CTTELEPHONE:
(707) 846-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Imelda Padama, Licensee & Samuel Padama, LicenseeTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and Non-Compliance (NCC) quarterly visit and was greeted by Ramil Gilbert "Chinchin" Razon, Caregiver/Designated Responsible Party. Imelda Padama, Licensee was contacted via phone and arrived shortly after and Samuel Padama, Licensee arrived approximately 2 hours later. LPA was informed there are three (3) residents in care and all were present during inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with a Hospice waiver for two (2), an approved dementia plan, and fire clearance for capacity of six (6) residents; five (5) non-ambulatory and one (1) bedridden.

At approximately 9:45 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed client showers with grab bars an non-slip mats as required. LPA observed a supply of clean linens, incontinent care products, and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. However, LPA observed toxic chemicals in the unlocked garage and outdoor storage building. Licensee removed and secured the items immediately making them inaccessible to residents in care. Facility has at least two days of perishable foods and one week of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities. LPA observed an activity schedule and games available for resident use.

Facility has two fire extinguishers, which were last inspected July 2024 and are fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Continued on 809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 13
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: 07/17/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 809...

Facility conducts yearly disaster drills, and the most recent drill was conducted July 2023. LPA informed Licensees, per Title 22 regulation, disaster drills shall be conducted on a quarterly basis. LPA observed the facility's infection control plan, first aid kit, PPE, other emergency supplies, and a back-up generator. There was no emergency water supply present as required per regulation. LPA informed Licensees that they shall purchase water to bring the facility into compliance. LPA reviewed facility's emergency disaster plan last updated April 2023.

At approximately 11:00 AM, five (5) staff files and three (3) resident files were reviewed. All staff files reviewed have the required CPR and First Aid training certificates, as well as documentation of all required initial training hours. Two (2) of five (5) staff files reviewed were missing proof of required annual training and annual medication training. LPA provided Licensees a copy of sections 1569.625 and 1569.69 from the California Health and Safety Code as is pertains to required staff annual and annual medication training in RCFEs. This is a repeat violation within a 12-month period. LPA cited California Code of Regulations, Title 22, Division 6, Section 871411(c) and issued civil penalties in the amount of $250. LPA advised Licensees to ensure all required documentation is in staff files and available for inspection upon request. LPA observed two (2) of three (3) resident files missing a signed Individual Service Plan as required per regulation and cited (see LIC809D). LPA observed all remaining required documentation present in all resident files prior to conclusion of today's inspection. Licensee states residents' families coordinate and arrange transportation to and from their medical and dental appointments. Facility does not manage cash resources for residents. LPA reviewed facility's medications and medication records which are not maintained in compliance with regulation, resulting in LPA issuing a citation (see LIC809-D).

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC610- Emergency Disaster Plan

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Licensee.

Exit interview conducted with Licensee, whose signature on this document confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 07/17/2024 07:21 PM - It Cannot Be Edited


Created By: Julie Florio On 07/17/2024 at 06:13 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: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 resident files reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
1
2
3
4
 Licensee to submit LIC9098 self-certifying training for staff on the proper documentation and administration of medications completed to CCLD by POC due date 7/18/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 07/17/2024 07:21 PM - It Cannot Be Edited


Created By: Julie Florio On 07/17/2024 at 06:13 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: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 resident records reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
Plan of Correction
1
2
3
4
Licensee shall submit proof of completed and signed Individual Service Plan for R1 and R2 to CCLD by POC due date 8/17/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 records reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
Plan of Correction
1
2
3
4
Licensee shall submit proof of completion of quarterly emergency disaster drill signed by all staff to CCLD by POC the required due date 8/17/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 07/17/2024 07:21 PM - It Cannot Be Edited


Created By: Julie Florio On 07/17/2024 at 06:19 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: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
871411(c)


This requirement is not met as evidenced by:
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:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 5 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
Plan of Correction
1
2
3
4
Licensee shall submit proof of completion of all required annual and annual medication training for S1 and S2 to CCLD by POC due date 8/17/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
Page: 13 of 13