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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 07/10/2023
Date Signed: 07/10/2023 04:55:07 PM


Document Has Been Signed on 07/10/2023 04:55 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:
07/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Imelda Garcia, Assistant ManagerTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and was granted access into the facility. LPA met with House Manager Imelda Garcia.
LPA toured the facility which was found to be at a comfortable temperature. LPA observed a supply of linens (bedding, towels, etc.), and cleaning solutions (observed locked & inaccessible). Resident bedrooms were furnished per regulation. Facility food supply was within regulation and accessible to residents. Medication was centrally stored. Fire Drill was conducted on 07/08/2023. There are 8 smoke detectors & 1 carbon monoxide detector, which were tested & observed operational. LPA reviewed staff and resident records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. The following deficiencies were observed during today's inspection:
Building Permit Violation:
During inspection, LPA observed 1 of 1 constructed staff bedroom located in the garage with a 1 bed and 1 bunk-bed, dresser, and personal belongings (photos taken). Staff (S1) unlocked the door from the inside of the staff bedroom in the garage and stated they were currently off work and getting dressed. The facility does not have a building permit for the staff bedroom in the garage and staff are occupying the bedroom at this time. Facility did not submit a building permit to CDSS CCL as required. Administrator stated the staff only use the bedroom to store their belongings on their shift. LPA previously discussed with Administrator on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022 that the bedroom is required to be inspected and approved by the Fairfield Fire Department, and Licensee must obtain a building permit to ensure it is safe for staff to occupy. Administrator understood.
**LPA informed licensee that individuals (specifically staff) are not allowed to sleep or occupy the shed in backyard, staff bedroom in the garage (which does not have a permit), or common areas (living room couch, etc.). Facility will operate with an awake staff as there are no staff rooms approved.
Fire Safety Violation:
During inspection, LPA observed 2 of 2 fire extinguishers were charged but last serviced over 1 year ago on 03/15/2023 (photos taken). LPA discussed with Administrator that fire extinguishers shall be serviced annually per regulation. 3 of 6 resident bedroom direct exits were blocked by (R5) chair, (R3) night stand with TV and TV tray, and (R2) by residents bed. photos taken
Report continued on LIC809-C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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 6


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: 07/10/2023
NARRATIVE
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Staff Training & Health Screening Violation:
During record review, it was revealed staff have not completed or have documented initial or annual training as required. Additionally LPA observed 5 of 5 staff records reviewed did not have a health screening completed with TB test as required. (photos taken)
Medical Assessments, Appraisals, & TB Test Violation:
File review revealed resident (R1 who is diagnosed with dementia) has a Medical Assessment (LIC602A) that is out of date, last completed on 03/21/2022 and their Appraisal Needs and Service Plan (LIC625) is also out of date (photos taken). Resident R5 is missing a completed LIC 625. Resident R3 requires a Tuberculosis (TB) test done. Additionally have Resident (R4) re-assessed for their ambulatory status due to being Bedridden on their LIC 602 but LPA observed resident walking during inspection. House manager stated R4 is non-ambulatory.
Maintenance & Operation:
LPA tested the water temperature during inspection. LPA observed kitchen sink faucet water to be 132 degrees F but had a yellow warning sign "Caution Hot Water" per regulation. LPA tested water temperature in the 2 of 2 resident's bathrooms (which are used by residents) which were 132.4 degrees F. Assistant manager lowered water temperature during inspection on water heater and notified House Manager Enrique.

LPA requested the following updated forms to be submitted to Community Care Licensing by 08/10/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Liability Insurance
· LIC 9020 Facility Register of Client/Residents
· LIC 610E Emergency Disaster Plan
· Copy of current Administrator's Certificate
LPA requested an updated facility indoor and outdoor sketch showing the newly built shed in the backyard.

Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Provided. *** An immediate civil penalty in the amount of $500 was assessed for blocking direct fire exit in resident R2 and R3's room
Exit interview conducted with Assistant Manager, whose signature on this document confirms receipt. This report was emailed to Administrator
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/10/2023 04:55 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
83507(a)

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87305 Alterations to Existing Building or New Facilities - (a) Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement was not met as evidenced by:
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Licensee to obtain a building permit for the constructed staff room in the garage or take down the staff room in the garage. Licensee to submit a plan of how they will correct the deficiency and ...
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Based on observation and statements received, Licensee did not comply with the above regulation in that staff are occupying a constructed bedroom in the garage which does not have a permit. This is a potential health and safety risk to residents in care.
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... a statement that they understand the regulation and staff will not occupy or sleep in the garage or any common areas (shed, couch, etc). Facility will operate with an awake staff. Licensee to submit plan of correction by 07/13/2023 to Community Care Licensing
Type A
07/13/2023
Section Cited
CCR87307(a)(2)(B)

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement was not met as evidenced by:
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 Licensee to submit proof (invoice and/or pictures) of serviced fire extinguishers and a written statement that they understand the regulation and will be in future compliance. Licensee to unblock resident's direct exits and rearrange furniture. Licensee to submit pictures as proof of correction
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Based on observation and statements received, Licensee did not comply with the above regulation in that 2 of 2 fire extinguisher was charged but last serviced 03/15/2022. Fire exits were blocked in Room 2, 3, and 5. This is an immediate health and safety risk to residents in care.
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POC due by 07/13/2023 to Community Care Licensing.
An Immediate Civil Penalty of $500
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 07/10/2023 04:55 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health... verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 5 staff who do not have health screening and TB test completed as required. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Licensee to have all staff obtain a health screening with TB test and submit copies to Community Care Licensing for review by POC due date 07/24/2023. Licensee to notify CCL if more time is needed.
Type B
Section Cited
CCR
87411(c)
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 5 staff who do not have any initial or annual training documented or completed. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Licensee to have all staff trained per regulation and submit copies as proof of correction. Training to include date, time, participant name and signature, subject, duration, and trainer name. POC due date 07/24/2023
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 07/10/2023 04:55 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above in 1 of 6 residents (R1). This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Licensee to have resident (R1) assessed and complete an updated LIC602A and update their Appraisal Needs and Service Plan (LIC625). Resident R5 to have a LIC 625 completed. Additionally have Resident (R4) re-assessed for their ambulatory status.
Type B
Section Cited
CCR
87458(b)(1)
87458 Medical Assessment (b)The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above in 1 out of 6 residents (Residet R3). This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Licensee to have Resident (R3) tested for TB as required. Licensee to submit proof of TB test results to Community Care Licensing by POC due date 07/24/2023.
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 07/10/2023 04:55 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the water temperature tested in resident's bathrooms was 132 degrees F, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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House Manager lowered the water temperature during inspection. Licensee to submit a log of water temperature from 7/10/23 to 7/14/2023. Licensee to submit a written statement that they understand the regulation and will be in future compliance by POC due date 07/14/2023
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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6