486803847-10-17-2023-21-AS-FSAI-CWPSMX-20231017140040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803847
Report Date: 10/17/2023
Date Signed: 10/17/2023 02:00:45 PM

Document Has Been Signed on 10/17/2023 02:00 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	L & S GENTLE CARE		FACILITY NUMBER:	486803847
ADMINISTRATOR:	PADAMA, SAMUEL		FACILITY TYPE:	740
ADDRESS:	162 N ALAMO DRIVE		TELEPHONE:	(707) 246-1100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	6	CENSUS: 6	DATE:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Unassociated Adult, Michael Belaguin Facility Manager, Enrique Marpa		TIME COMPLETED:	02:15 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	Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at L & S Gentle Care for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by an Unassociated Adult, Michael Belaguin, who presented himself as the Assistant Administrator/in charge. LPA was granted access into the facility. A review of the Guardian Background Clearance revealed that the unassociated adult is associated to other facilities in another California County. Facility Manager, Enrique Marpa arrived 1 hour and 30 minutes later. LPA educated the Facility Manager on the importance of ensuring that ALL staff members are associated to the facility (See LIC 9102-Technical Advisory). LPA toured the facility. The facility was inspected and found to be clean and in good repair at the time of the inspection with all exits free from obstruction. During the tour, LPA observed an Accessory Dwelling Unit structure that is primarily utilized for storage. LPA confirmed by inspecting the inside of the unit with the Facility Manager once he arrived at the facility. LPA requested facility to update there sketch and send it to CCL (See LIC 9102-Technical Advisory). Fire Extinguishers are dated for July 2023. Smoke detectors and carbon monoxide detectors were found to be operational at the time of the inspection. Hot water temperature measured at 110 degrees in 2 of 2 residents bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Medications were centrally stored and locked. Facility has first aid kit which was inspected and found to be appropriate during the Required 1 year inspection. Activities menu and food menu was available for viewing during the inspection. There was a sufficient supply of both perishable and non-perishable foods located in the garage and in the kitchen. Special diets are in place for residents who require special diets. There is outdoor space for activities. LPA observed the Portable Emergency Generator in the garage and accessible in case of an emergency and/or power outage occurs. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: L & S GENTLE CARE	FACILITY NUMBER: 486803847
	VISIT DATE: 10/17/2023

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LPA will review staff, resident and facility records which includes the Emergency Disaster Plan and the Infection Control Plan at a later date and time. In addition, LPA will conduct staff and resident interviews at a later date and time. Annual Continuation is required. No deficiencies were cited during this Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Facility Manager.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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