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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 03/01/2022
Date Signed: 03/01/2022 04:28:45 PM

Document Has Been Signed on 03/01/2022 04:28 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 IIFACILITY NUMBER:
486803974
ADMINISTRATOR:PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:778 APPALOOSA CTTELEPHONE:
(707) 846-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
03/01/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Imelda Padama, LicenseeTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Karina Canela arrived at L & S Gentle Care II to conduct an unannounced post-licensing inspection on 03/01/2022. LPA met with Imelda Padama, Licensee. LPA observed 6 residents in care. LPA discussed Emergency Disaster Drills to be conducted every 3 months.

During today’s visit LPA observed the following items:
· COVID-19 postings and screening station at entrance.
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip mats in 2 of 2 bathrooms.
· Fire Extinguisher charged
· Required furnishings in all 6 resident bedrooms
· Administrator Certification (expires 11/28/2022); Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Emergency Disaster Plan, and visitor policy).
· Water temperature was tested and within regulation of 105 to 120 degrees F
· Auditory devices observed operational
· Resident's medication was centrally stored
· Food supplies were within regulation
· Facility records were reviewed for residents and staff.

Report continued on LIC 809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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 II
FACILITY NUMBER: 486803974
VISIT DATE: 03/01/2022
NARRATIVE
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During the inspection, LPA observed the following deficiencies (pictures taken):
  • Half bed rails in resident bedrooms 2 - 6 and full bed rail in resident bedroom 1. As of 03/01/2022, Community Care Licensing Department (CCLD) has not received or approved an exception request for postural support - full bed rail. Additionally, LPA reviewed resident files and 6 of 6 residents do not have a prescription for the half bed rails used only for assistance with mobility. Licensee contacted the resident's doctors during inspection.
  • Resident (R1) observed with a lap belt in wheel chair. As of 03/01/2022, CCLD has not received or approved an exception request for postural support - lap belt device. Licensee stated the device is used for safety for R1 not to fall out of the wheelchair.
  • Cleaners and disinfectants observed unlocked and accessible in the laundry room (on the laundry room floor: 3 containers of liquid detergent, 2 containers of clorox; and in unlocked laundry cabinet: 3 containers of lysol toilet cleaner, 1 jug of fabuloso cleaner, and 5 spray bottle containers of non-labeled cleaning solution). Licensee locked cleaners and disinfectants during inspection.
  • LPA observed alterations to the facility including a second backyard gate and a bedroom in the garage for staff use.
  • Fire extinguisher observed without a service tag. Licensee stated the fire extinguisher was bought new and thought it did not need to be serviced until 1 year.
  • Topical medications (4 tubes) in Resident (R2)'s bedroom. Licensee stated staff were using it and forgot to lock
  • 2 of 2 backyard fence gates observed with a key chain trail metal clip. Licensee stated a neighbor's home was broken into and the facility felt safer with securing the fence gates. As of 03/02/2022, CCLD has not received a waiver request to secure the perimeter. Licensee stated they would request a waiver to lock/secure the perimeter from CCLD. Licensee removed during this visit and stated they understood the requirement.

Report continued on LIC 809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 II
FACILITY NUMBER: 486803974
VISIT DATE: 03/01/2022
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  • Individual (I1) was observed working and providing care to residents without being associated as required. LPA verified with L & S Gentle Care II faciltiy personnel roster printed on 03/1/2022


LPA explained prior to anyone working (including shadowing a staff and/or training), volunteering, residing or being present in any part of the licensed facility, they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation.

Licensee stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at a licensed facility, the individual must obtain a fingerprint clearance and be associated to the facility.


A Civil penalty in the total amount of $100.00 was assessed today for individual (I1), who was not fingerprint cleared to this facility as required. Licensee associated the individual during today's inspection. LPA verified with CCL Santa Rosa Regional Office that I1 was associated as of 03/01/2022


Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Imelda Padama, Licensee, whose signature below confirms receipt.

LPA discussed with licensee regarding lawful evictions.

LPA requested documentation for staging of R1's wound to be submitted to CCL by 03/08/2022

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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Document Has Been Signed on 03/01/2022 04:28 PM - It Cannot Be Edited


Created By: Karina Canela On 03/01/2022 at 02:08 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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2022
Section Cited
CCR
87309(a)

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87309 Storage Space - (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Licensee locked cleaners and disinfectants during inspection. Licensee to submit a statement that they understand the requirement and will be in future compliance with the regulation by POC due date 03/08/2022 to Community Care Licensing
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Based on observation and interviews, Licensee did not ensure cleaners and disinfectants were stored locked and inaccessible to residents.
This is an immediate health & safety risk to the residents in care.
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Type B
03/08/2022
Section Cited
CCR87355(e)(2)

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87355 Criminal Record Clearance - (e)All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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Licensee associated I1 during inspection. Licensee to submit a written statement they understand the requirement and will be in future compliance with the regulation by POC due date 03/08/2022 to Community Care Licensing
**Civil Penalty assessed in the amount of $100.00
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Based on record review, observation, and interviews conducted: Licensee did not obtain a criminal record clearance for individual (I1) prior to working at the facility.
This is a potential safety risk to the residents 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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


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Document Has Been Signed on 03/01/2022 04:28 PM - It Cannot Be Edited


Created By: Karina Canela On 03/01/2022 at 03:30 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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2022
Section Cited
CCR
87608(a)(1)

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87608 Postural Supports - (a) ... the facility shall provide assistance and care for the resident...(1) Postural supports shall be limited to appliances or devices...used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position...
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Licensee to request an exception for postural support - lap belt for wheel chair and include supporting documentation. Licensee to submit exception request with supporting documentation to CCL to clear the citation by POC due date 03/08/2022
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This requirement was not met as evidenced by: based on observation, interviews, and record review, licensee did not ensure the regulation above with resident (R1) observed with a lap belt on wheelchair. This is a potential health, saftey and personal rights risk to residents in care.
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Type B
03/08/2022
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports -(a)...the facility shall provide assistance and care for the resident...(5) ...(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Licensee to request an exception for postural support - full bed rails and include supporting documentation or remove the full bedrails. IF half bedrails are used, Licensee shall obtain a perscription from the resident's doctor. Licensee to submit copies of perscriptions for R3 - R6.
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This requirement was not met as evidenced by: based on observation, interviews, and record review, licensee did not ensure the regulation above with resident (R2) observed with full bed rails. This is a potential health, saftey and personal rights risk to residents in care.
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Licensee to submit an exception request, physician perscription, and supporting documents to CCL to clear the citation by POC due date 03/08/2022
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


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