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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 10/29/2024
Date Signed: 10/30/2024 12:10:11 PM

Document Has Been Signed on 10/30/2024 12:10 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: DATE:
10/29/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Imelda Padama, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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A Subsequent Non-Compliance Meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio, and Licensee, Imelda Padema.

The purpose of the Subsequent Non-Compliance Meeting was to discuss areas of non-compliance and ongoing observed concerns during inspection on September 19, 2024, in the of the operation of L & S Gentle Care II, facility #486803974. Facility was placed on a Non-Compliance Plan on 07/13/2023 and received Technical Support Provider (TSP) consultations on 08/14/2023 and 08/28/2023. Today, the Licensee were informed that further and/or repeat citations may result in extending the facility’s non-compliance plan or possibly administrative action. The legal administrative action process was explained to attendees.

Items addressed in today's meeting include patterns of non-compliance in the following areas:

1. Fire Clearance/Live-in Staff: Staff shall not sleep or reside in un-permitted/uncleared rooms or facility communal areas, (see pictures). LPA Karina Canela cited for the same deficiency 07/10/2023 after numerous discussions regarding the same issue on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022.
2. Staffing: Staff must be sufficient in numbers to provide adequate care and supervision to residents in care.
3. Staff Training: Staff must complete initial training hours prior to working independently with residents.
4. Staff Medication Administration Training: Staff shall be complete initial training hours prior to working independently with residents.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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: 10/29/2024
NARRATIVE
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Continued from LIC809...

5. Personnel Records: Staff records shall be complete with required documentation.
6. Client Records: Client records shall be complete with required documentation.
7. Administrator Qualifications and Duties: The administrator shall be present a sufficient number of hours to ensure facility is operating within compliance.
8. First Aid Requirements: The administrator shall ensure that all staff have proof of current First Aid given by American Red Cross.
9. Buildings and grounds: The shed in backyard and storage room in the garage were both observed unlocked with chemicals inside, as well as chemicals and a bottle of alcohol in an unlocked cabinet in the laundry room.
10. Submission of requested documents by due dates

Documents requested during September 19, 2024, facility visit were not provided to CCL. Below documents were requested again during today’s meeting and Licensees agrees to submit to CCL by 11/15/2024:

· LIC500 personnel summary and include all staff specific days/hours on shift, including administrator.
· LIC9020 – Register of Residents

Citations and Civil Penalties issued today:

1. Licensee was informed that a citation and an immediate civil penalty are being issued today for the personnel requirements violation observed during Case Management – Legal Non-Compliance quarterly visit conducted on September 19, 2024, due to staff files for S1 and S2 did not have proof of initial training hours completed and were observed working independently with residents. Upon interview with Licensee and staff, LPA discovered that the staff both started the day prior, 09/18/2024. Facility was cited for the same deficiency during Case Management – Legal Non-Compliance quarterly visits on 04/12/2024 and 7/17/2024. This is the second repeat of this violation within a 12-month period, (see LIC809D).

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

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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: 10/29/2024
NARRATIVE
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Continued from LIC809C...

2. Licensee was informed that a citation is being issued today for a care of persons with dementia violation observed during Case Management – Legal Non-Compliance quarterly visit conducted on September 19, 2024, where Licensee did not ensure that R1’s physician ordered alcohol was kept in a secure place that is not accessible to persons in care. LPA observed an almost full 1.75-liter bottle of Seagram’s Extra Dry Gin on a shelf in an unlocked cabinet in the facility’s unlocked laundry room, along with a bottle of bleach and a bottle of laundry detergent. LPA further observed cleaning and toxic chemicals accessible to residents in care in the unlocked garage, unlocked storage room in the garage, and the unlocked storage shed in the backyard (see pictures), (see LIC809D).

3. Licensee was informed a citation is being issued for staff medication administration training due to upon observation, interview, and record review, LPA discovered that new staff (S1 and S2) passed medications to the residents in care the morning of 9/19/2024 without having completed any documented medication administration training. Further it was revealed that both staff were hired on 9/18/2024, (see LIC809D).

4. Licensee was informed a citation is being issued for resident records due to LPA observing numerous required documents either incomplete or missing from multiple residents’ records upon file review, (see LIC809D). The following documents were observed incomplete or missing from the indicated residents’ records:

§ Proof of Negative TB results: R1
§ Admissions Agreement not signed and/or dated: R1 & R4
§ 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
§ Centrally Stored Medication Destruction Record (CSMDR): R1
§ LIC601 - Identification and Emergency Information: R1 & R4

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

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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: 10/29/2024
NARRATIVE
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Continued from LIC809D...
5. Licensee was informed a citation is being issued for staff living/sleeping in the un-permitted/uncleared room in the garage and communal areas of the facility due to LPA’s observation and staff interviews which confirmed this was occurring (see pictures), (see LIC809D). Licensee was informed to be in compliance at all times with fire clearance on file which does not include clearance for the structure in the garage. Licensee informed LPA that they are unable to have the structure permitted due to costs involved. Licensee was informed to contact local code enforcement to request written approval to use the room for storage only, followed by approval from the local fire department. If unable to get approval, Licensee has agreed to disassemble the structure in the garage.

6. Licensee was informed a citation is being issued for personnel records due to LPA’s observation, interviews and record review which revealed numerous required documents were either incomplete or missing from multiple staff members’ records as observed during file review and as noted below, (see LIC809D).

· Proof of First Aid Certification: S1, S2, & S3
· Proof of CPR certification: S1 & S3
· LIC501: Job application: S1, S2, S5, S7, & S9
· LIC503: Health Screening: S1, S2, S3, S6, S7, & S10
· Proof of Negative TB results: S1, S2, S3, S4, S6, S7, & S10
· Initial Orientation and Training Hours: S1 & S2
· Initial Medication Administration Training Hours: S1 & S2

7. Licensee was informed a citation is being issued for administrator duties and qualifications due to LPA’s observations, interviews, and record review which revealed that adequate attention to the management and administration of the facility was not occurring as evidenced by the above noted deficiencies and that administrator had untrained staff working independently, (see LIC809D).

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation or the California Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Licensees and appeal of rights provided. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/30/2024 12:10 PM - It Cannot Be Edited


Created By: Julie Florio On 10/29/2024 at 02:10 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: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
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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safety, and personal rights risk to persons in care.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1 and S2 who Licensee stated were hired the day prior, 9/18/2024 and who LPA observed working independently with residents which poses a potetnial health,
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Licensee to submit self-certification stating they "will ensure all the required staff training is complete and documented proof is made available for licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.
Type B
10/30/2024
Section Cited
HSC1569.69

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§1569.69 Employees assisting residents with self-administration of medication; training requirements:a) ... 2) ...the employee shall complete...two hours of hands-on shadowing training...prior to assisting with the self-administration of medications....This requirement is not met as evidenced by:
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potential health, safety, and personal rights risk to persons in care.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1 and S2 who addmitedly gave medications on the morning of 09/19/2024 without completing any medication training which poses a
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Licensee to submit self-certification stating they "will ensure the required staff medication administration training is complete prior to staff giving medications and documented proof is made available for licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.
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: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 12:10 PM - It Cannot Be Edited


Created By: Julie Florio On 10/29/2024 at 03:05 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: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia f) The following shall be stored inaccessible to residents with dementia: (2) ...alcohol, ... and toxic substances such as certain..., gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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Licensee to submit self-certification stating they will ensure all alcohol, solutions and chemicals which pose a risk to persons in care are stored inaccessible to residents to CCL by POC due date 10/31/2024 EOB.
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Based on observation Licensee did not ensure that alcohol, cleaning solutions, and chemicals were kept in a secure place that is not accessible to residents, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
10/30/2024
Section Cited
CCR87307(a)

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87307 Personal Accommodations and Services: (a) ....The facility shall...provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
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Licensee to submit self-certification stating they will ensure no staff are living or sleeping in the structure in the garage or in communal areas of the faciity, as well as provide written proof that they have contacted Code enforcement requesting approval to use the room for
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Based on observation and interviews the Licensee did not ensure that staff who may reside or sleep in the facility are provided private accommodations within the scope of their fire clearance which poses an immediate health, safety, and personal rights risk to persons in care.
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storage only to CCL by POC due date 10/31/2024 EOB.

Additionally, Licensee to submit written proof of the decision from Code Enforcement to CCL by second POC due date 11/15/2024.
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: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 10/30/2024 12:10 PM - It Cannot Be Edited


Created By: Julie Florio On 10/29/2024 at 03:49 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: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87506(a)

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87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Licensee to submit self-certification stating they "will ensure all resident files have all of the required paperwork prior to admitting residents and will have it available to Licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for R1, R2, R4, and R5 whose files were all missing two or more required documents which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
10/30/2024
Section Cited
CCR87412(a)

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
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Licensee to submit self-certification stating they "will ensure all staff files have all of the required paperwork prior to staff beginning work in the facility and will have it available to Licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1, S2, S3, S4, S5, S6, S7, S9, and S10 whose files were all missing one or more required documents which poses a potential health, safety, and personal rights risk to persons in care.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 10/30/2024 12:10 PM - It Cannot Be Edited


Created By: Julie Florio On 10/29/2024 at 04:05 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: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87405(a)

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. 87405 Administrator - Qualifications and Duties: (a)....The administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility....This requirement is not met as evidenced by:
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Licensee to submit an updated LIC500 to include the hours they will present in the facility as well as a self-certification stating they "will ensure they are present enough to bring the facility into compliance with regulation" to CCL by POC due date 11/29/2024 EOB.
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above in ensuring compliance and by having untrained staff working independently which poses a potential health, safety, and personal rights risk to persons in care.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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