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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 07/09/2025
Date Signed: 07/09/2025 02:42:53 PM

Document Has Been Signed on 07/09/2025 02:42 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: 4DATE:
07/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Imelda Padama - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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At approximately 9:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-Year Visit and Non-Compliance (NCC) quarterly visit and was greeted by caregivers Ronald Lazaro and Laila Lazaro. In addition, a private caregiver that a family member had hired to support a resident was present from the ABBA agency.
Although not required, it was recommended that this private caregiver be associated to the facility if long term care continues.
Imelda Padama, Licensee was contacted via phone and arrived at approximately 10:30 AM. LPA was informed there are four (4) 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 resident in room #4 only.

At approximately 10:35 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, free from odors and passageways were free from obstructions. Water temperature in clients' bathrooms measured were above the required range of 105 to 120 degrees F per Title 22 regulations, and licensee had prominent signs warning of the hotter than normal water per regulation. A technical advisory was given to reduce the water temperature to reduce the risk or scalding injuries and licensee turned down the water heater while I was in the facility.

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.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/09/2025 02:42 PM - It Cannot Be Edited


Created By: Star Stevenson On 07/09/2025 at 01:43 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: 07/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above in three (3) out of four (4) residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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Licensee immediately removed prescription and non-prescriptiion/PRN medicines not allowed per MD LIC602 reports and Licensee agrees to review regulation 87465(h)(2) before 07/10/2025 and will provide the names and times all the staff at L & S Gentle Care II will have review/training on regulation 87465(h)(2)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


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: 07/09/2025
NARRATIVE
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Continued from LIC809
LPA observed toxic chemicals under the sink of bedroom number six (6) and Licensee immediately removed and secured the items making them inaccessible to residents in care.

Three (3) of four (4) residents rooms, residents R1, R2 and R3 were noted to have a combination of unsecured prescription and non-prescription medicines and a type A deficiency was cited. In addition, it was noted that one (1) of 4 residents (R1) had over-the-counter (OTC) medicines in their room despite their LIC602 indicating the inability to manage or store their own meds and a Technical Violation (TV) was issued.

LPA noted that 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. A locked shed was noted to have extra supplies. LPA observed an activity schedule and games available for resident use.

Facility has two fire extinguishers, which were last inspected July 2025 and are fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Facility conducts disaster drills every three (3) months, and the most recent drill was conducted July 2025. LPA observed the facility's infection control plan, first aid kit, PPE, other emergency supplies, and a back-up generator. LPA noted emergency water supply present as required per regulation.

At approximately 11:30 AM, five (5) staff files and four (4) resident files were reviewed. All staff files reviewed had the required CPR and First Aid training certificates, as well as documentation of health and TB clearance and training hours. One (1) of five (5) staff files were not maintained at the facility and needed to be brought over from their sister facility and a technical violation was issued.

At approximately 12:30 PM LPA observed one (1) of four (4) resident files missing a pre-placement appraisal, appraisal service and needs plan, signed personal rights, or consent for emergency medical treatment and licensee set out to have items signed by resident that could sign for themselves and a technical violation was issued.
Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: 07/09/2025
NARRATIVE
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Continued from LIC 809C
Licensee states residents' families coordinate and arrange transportation to and from their medical and dental appointments. Facility does not manage cash resources for residents.

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

1)LIC610- Emergency Disaster Plan
2)LIC500 - Personnel Report
3)Updated Liability insurance
4)LIC9020 - Registration of facility residents.

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
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC809 (FAS) - (06/04)
Page: 9 of 9