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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:22:46 PM

Document Has Been Signed on 09/19/2024 04:22 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: 5DATE:
09/19/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Imelda Padema, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Julie Florio arrived unannounced for the purpose of conducting a quarterly Non-Compliance (NCC) visit and was greeted by new Staff 1 (S1) and new Staff 2 (S2). Licensee, Imelda Padema was contacted via telephone and arrived at approximately 10:30 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with five [5] residents in care and one more moving in this weekend.

At approximately 10:40 AM, LPA toured facility with Licensee and observed the following: LPA observed cleaning detergent, bleach and a bottle of Seagram's Extra Dry Gin unsecured in the facility laundry area. Licensee secured the items immediately and stated the Gin was for a resident with physician's order for it. LPA confirmed the physician order and informed Licensee that the alcohol needs to be secured, Licensee locked the alcohol in the medication closet immediately. LPA also observed cleaning supplies and chemicals in the garage which was accessible to residents in care. Licensee states they will have the laundry room door installed with a lock.

LPA observed that the constructed bedroom in the garage is being used by staff as sleeping/living quarters as evidenced by two open suitcases and additional bags filled with clothing and personal items and a sleeping cot set up (See pictures). LPA informed Licensee that the room is not permitted for staff or resident use. The room shall be used for storage only. Staff 1 (S1) stated they sleep on the couch in the facility. LPA informed S1 and Licensee that no staff or resident shall sleep in a common area of the facility per regulation. LPA observed the shed in the backyard to be unlocked with chemicals and tools accessible to residents in care. The shed was being used only for storage. LPA informed Licensee that the outdoor shed shall be locked at all times. LPA, Karina Canela cited the facility for these same areas of concern on 7/10/2023 after several discussions regarding the same issues on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022. Today, LPA Florio re-emphasized that the "facility does not have a building permit for the staff bedroom in the garage and staff are occupying the bedroom at this time. Facility did not submit a building permit to CDSS CCL as required.... [T]he bedroom is required to be inspected and approved by the Fairfield Fire Department, and Licensee must obtain a building permit to ensure it is safe for staff to occupy.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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 3
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: 09/19/2024
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Continued from LIC809...

[Licensee] understood. LPA informed [L]icensee that individuals (specifically staff) are not allowed to sleep or occupy the shed in backyard, staff bedroom in the garage (which does not have a permit), or common areas (living room couch, etc.)." Again today, Licensee assured LPA that the "facility will operate with an awake staff as there are no staff rooms approved."

Licensee informed LPA there are no pre-poured medications being administered. Licensee stated they wait until it is time to administer residents' medications and bring them to her desk in the front room/office area to dispense one residents' medications at a time to minimize medication errors.

LPA asked for the new staff members' files. Licensee stated that S1 has the required paperwork but that they are still working on S2's paperwork. Licensee stated three staff recently quit working at the facility and "it's been really hard."

LPA conducted a record review of ten [10] out of ten [10] staff files. LPA observed the following missing items for the indicated staff:

First Aid: S1, S2, & S3
CPR: S1 & S3
LIC501 - Personnel Application: S1, S2, S5, S7, & S9
LIC503 - Health Screening: S1, S2, S3, S6, S7, & S10
Proof of Negative TB: S1, S2, S3, S4, S6, S7, & S10
Initial Orientation and Training Hours: S1 & S2
Initial Medication Administration Training Hours: S1 & S2

LPA conducted a record review of five [5] of five [5] resident files. LPA observed the following missing items for the indicated residents:

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 09/19/2024
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Continued from LIC809C...

Proof of Negative TB: R1
Admissions Agreement not signed and/or dated: R1 & R4
Centrally Stored Medication Destruction Record (CSMDR): R1
LIC9172 - Functional Capability Assessment: R1, R2, R4, & R5
LIC625 - Appraisal/Needs and Services Plan: R1, R2, R4, & R5
Consent for Emergency Medical Treatment: R1, R2, R4
LIC601 - Identification and Emergency Information: R1 & R4

***Additionally, the CSMDR, for each resident that did have them, were found to be maintained out of compliance with regulation as evidenced by incorrect fill, start, and expiration dates, pill quantities, number of refills, and filling pharmacies.

LPA requested the following updated forms to be submitted to Community Care Licensing within 30 days of today's visit:

· LIC 500 Personnel Report
· LIC 9020 Facility Register of Client/Residents

***LPA informed Licensee that CCL will be scheduling an informal meeting in the regional office to discuss today's inspection and areas of concern. LPA also informed Licensee that citations and civil penalties may be issued at that time.

No deficiencies were cited during today's inspection.

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

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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