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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 12/05/2024
Date Signed: 12/05/2024 01:47:39 PM

Document Has Been Signed on 12/05/2024 01:47 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) 246-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Maggie Alfonso, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At approximately 12:35 PM, icensing Program Analyst (LPA) Julie Florio arrived unannounced for the purpose of conducting a quarterly Non-Compliance (NCC) visit and was greeted by Staff 1 (S1) and new Staff 2 (S2). Licensee, Imelda Padema was contacted via telephone and informed LPA that she was out of the facility today and would be unable to make it for the inspection. Licensee gave permission for S1 to sign for today's visit. Facility is a Residential Care Facility for the Elderly (RCFE) with 5 residents in care -- 2 of whom are currently on Hospice and 1 is bedridden but is in the hospital.

At approximately 12:50 PM, LPA initiated a facility tour with Designated Responsible Party (DRP) and observed the following: facility was a comfortable temperature, passageways were free from obstructions, items which could pose a risk to residents in care were observed inaccessible and cabinets containing such items were locked. Medications were properly stored. LPA inspected the structure in the garage which did not contain any personal items, clothing, or sleeping materials, indicating the room is being used strictly for its approved purpose of storage.

At approximately 1:10 PM, LPA reviewed new resident and new staff files which had all the required documentation except S2 has not yet completed their CPR/First Aid Training but is scheduled to complete it.

No deficiencies cited during this inspection.

Exit interview conducted with DRP, whose signature confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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