<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 06/02/2022
Date Signed: 06/02/2022 05:50:24 PM

Document Has Been Signed on 06/02/2022 05:50 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:
06/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee Imelda PadamaTIME COMPLETED:
06:15 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) Karina Canela arrived unannounced at L & S Gentle Care II on 06/02/2022 for the purpose of addressing deficiencies observed during an investigation regarding complaint #21-AS-20220228080816. LPA met with Licensee Imelda Padama.
Prohibited Health Condition: Resident (R1)'s records reviewed revealed R1 developed a stage 3 pressure injury while in care on an unknown date. Facility staff notified R1's authorized representative on 02/28/2022. Administrator did not notify Community Care Licensing and did not request an exception to retain a resident (R1) with a prohibited health condition.
Unlawful Eviction: Statements received revealed licensee gave R1's authorized representative a verbal improper/unlawful eviction. Licensee did not follow eviction procedures as required per regulation 87224. This resulted in R1's authorized representative removed R1 from the facility on 03/02/2022.
Personal Rights Violation: During inspection dated 03/01/2022: LPA observed a visitor of resident (R2) visiting and stated they saw that the Licensee changed the visiting hours on weekends from 10 - 5pm to 10 - 3pm. R2's visitor expressed that it would be difficult to visit with the visiting hours changed. Licensee stated “that’s not for you, you can come whenever”. Licensee then stated they changed the visiting hours for R1's representative as they visit after 6pm and make staff "feel uncomfortable due to raising their voice". LPA stated the facility must allow reasonable hours for visitation. Additionally, LPA observed R1 sitting in their wheelchair wearing a shirt (arm length to elbow) while other residents had jackets or blankets on them. LPA felt R1's arm which was cold to the touch. LPA brought this to the attention of staff (S1). S1 stated R1 is "fine" and does not "like blankets and will throw it off". S1 asked R1 (who is mostly non-verbal) if they are cold, R1 responded "yes". LPA explained to Licensee that R1 felt cold to the touch, and seniors may get cold easily. LPA discussed with staff to be mindful of the comfort of residents.
Appeal Rights Provided.
Deficiencies cited (see LIC809-D pages) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee Imelda Padama, whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/02/2022 05:50 PM - It Cannot Be Edited


Created By: Karina Canela On 06/02/2022 at 01:15 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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
CCR
87615(a)(1)

1
2
3
4
5
6
7
87615 Prohibited Health Conditions: (a) Persons who require health services... specified below shall not be admitted or retained in a residential care facility for the elderly: (1)Stage 3...pressure injuries. This requirement was not met as evidenced by: Based on record review and interviews conducted:
1
2
3
4
5
6
7
Administrator to submit a written statement that they understand the regulation 87615(a)(1) and shall be in future compliance.
Administrator to submit statement as the Plan of Correction (POC) by due date 06/03/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation
8
9
10
11
12
13
14
 Administrator did not ensure the above regulation due to Resident (R1) sustaining a stage 3 pressure injury while in care and Admin did not request or was approved for an exception from CCL to retain R1 with a prohibited condition. This is a potential health, safety and personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type B
06/08/2022
Section Cited
CCR87224(a)

1
2
3
4
5
6
7
87224 Eviction Procedures:
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator to to review the regulation and submit a written statement that they understand the regulation 87224(a) and shall be in future compliance.
Administrator to submit statement as the Plan of Correction (POC) by due date 06/08/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation
8
9
10
11
12
13
14
Based on record review and interviews conducted: Administrator did not ensure the above regulation due to issuing a verbal eviction notice to R1's representative and not following proper eviction procedures. This is a potential personal rights risk to the residents in care.
8
9
10
11
12
13
14
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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/02/2022 05:50 PM - It Cannot Be Edited


Created By: Karina Canela On 06/02/2022 at 03:46 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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2022
Section Cited
HSC
87468.1(a)(11)

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities: (a) Residents... shall have all of the following personal rights:(11) To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
1
2
3
4
5
6
7
Administrator to submit a written statement that they understand the regulation 87468.1(a)(11) and shall be in future compliance to allow all resident's visitors to visit during reasonable hours and without prior notice.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on record review and interviews conducted: Licensee did not ensure the above regulation due to changing visitation hours to discourage R1's representative from visiting regularly. This is a potential personal rights risk to the residents in care.
8
9
10
11
12
13
14
Administrator to submit statement as the Plan of Correction (POC) by due date 06/08/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3