L & S Gentle Care II

Allegation investigated: Staff did not ensure assistance was provided to resident in care Staff was asleep while at work Staff dispensed medication not as prescribed to resident in care Staff financially abused resident in care

On 10/20/2023, Licensing Program Analyst, Carol Fowler arrived unannounced for the purpose of opening a 10-inital complaint investigation and delivering findings. LPA was greeted by Caregiver, Ramilgilbert Razon. LPA toured the facility with House Manager, conducted interview with resident (R1), Staff (S2, S3 & S4) LPA called S1 but was unsuccessful and unable to leave a voicemail. LPA received text messages and emails from RP. LPA conducted facility file/e-MAR review and made observations. Complaint alleges: Staff did not ensure assistance was provided to resident in care. During a tour of the facility, LPA observed a staff member assisting a resident with ADL's and another staff assisting a resident to her chair after breakfast. Based on interviews with staff and resident that was conducted, LPA learned of no concerns regarding the care of residents in care. Therefore, the allegation is UNSUBSTANTIATED. Continue on LIC9099C Unsubstantiated Continue from LIC9099 Complaint alleges: Staff was asleep while at work. LPA interviews with staff and resident revealed that there is no staff sleeping while on duty. House Manager Imelda Garcia stated that staff have breaks in the garage and on occasions leave the facility, S2 and S3 stated that staff take turns for breaks in the garage and for long breaks they leave the facility. Staff stated sleeping on the job is not expected of staff or allowed. Staff also stated that they have not observed staff sleeping on the job. Therefore, the allegation is UNSUBSTANTIATED. Complaint alleges: Staff dispensed medication not as prescribed to resident in care. LPA conducted record review e-MAR and interviews with staff and resident which revealed that the facility has not had any medication errors or issues. Based on the medication record and physician's orders on file, residents have received their required medications. Therefore, the allegation is UNSUBSTANTIATED. Complaint alleges: Staff financially abused resident in care. LPA interviewed staff and resident it is revealed that the facility is not responsible for residents finances. Interview conducted with resident (R1) revealed that staff has never asked R1 for money. Therefore, the allegation is UNSUBSTANTIATED. Report was reviewed with House Manager Imelda Garcia and copy was provided. No deficiencies cited during visit.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 21-AS-20231017145432

Type of visit: Case Management - Legal/Non-compliance

On 10/12/2023 Licensing Program Analyst (LPA) Carol Fowler arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, Raamil Gilbert. House manager Imelda Garcia arrived at 10:36am. LPA discussed NCC concerns and found that the facility has submitted updated plan for building permit and serviced fire extinguisher, service date 7/11/2023 to CCLD. LPA C. Fowler and House Manager Imelda Garcia toured the facility, LPA observed that the constructed bedroom in the garage is being used for storage, LPA was informed by House Manager that no staff is sleeping in the common areas. The shed in the backyard is locked and being used for storage. There are no pre-poured medications, water temperature is 119.6 within regulation of 105 to 120 F. LPA conducted a record review staff files have been updated with health screenings (TB tests) and current training's. R1, R3, R5 files have been updated, R4 has been discharged from the facility. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Oct 12, 2023

Type of visit: Office

The California Department of Social Services (CDSS) Community Care Licensing (CCL) Santa Rosa Regional Office conducted an informal meeting today 07/13/2023 by virtual calling with L & S Gentle Care II, 486803974. Present in the meeting were: Licensing Program Manager Kimberley Mota, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst Karina Canela , Licensee and Administrator Samuel Padama, Licensee Imelda Padama, House Manager Enrique Marpa, and Assistant to the House Manager Imelda Garcia. The purpose of this office meeting was to discuss areas of concern in the facility operation and putting L & S Gentle Care II facility on a Non-Compliance Conference (NCC) plan. Parties present during the meeting agreed to a NCC plan to bring the facility, L & S Gentle Care II, into compliance. Items addressed during the meeting include, but are not limited to, areas of concern: Compliance with California Title 22 Regulations and Community Care Licensing (CCL) Requirements Recent substantiated Department of Labor (DOL) complaint Fire Clearance and Safety Violations Reporting Requirements Facility Record Keeping Staff Training Requirements Additionally, Licensee understands staff shall not sleep or occupy any shed(s) on the premises, sleep in common areas of facility (living room couch, etc.) , and/or sleep/occupy constructed bedroom in the garage (unless approved by the Local Fire Department and a permit is obtained). Licensee understands pre-pouring medication is not allowed. Technical Support Provider (TSP) assistance was offered to Licensees during this meeting. *A copy of this report was emailed to Administrator; signature in file.the state’s words, verbatim · CDSS document, Jul 13, 2023

Type of visit: Required - 1 Year

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 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 Administratorthe state’s words, verbatim · CDSS document, Jul 10, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jul 13, 2023

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: 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.the state’s words, verbatim · CDSS document, Jul 10, 2023

Plan of correction: ... 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

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jul 13, 2023

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: 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.the state’s words, verbatim · CDSS document, Jul 10, 2023

Plan of correction: POC due by 07/13/2023 to Community Care Licensing. An Immediate Civil Penalty of $500

Allegation investigated: Facility failed to issue a refund

Licensing Program Analyst (LPA) Karina Canela arrived unannounced for the purpose of delivering complaint findings on complaint 21-AS-20230222133208. LPA met with Imelda "Mel" Garcia, Facility Manager. During the investigation LPA conducted interviews, reviewed documents requested. Complainant alleged that after resident, R1 passed away on 02/15/2023, R1's personal belongings were removed from the facility on 03/08/2023 or 03/09/2023, but they were not issued a refund in the correct amount. Facility stated belongings were removed on 02/25/2023. Facility issued a refund check on 02/15/2023 which was within the 15 days required by regulation. This Agency has investigated the complaint alleging "facility failed to issue a refund". We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted with Imelda "Mel" Garcia, Facility Manager. *Nothe state’s words, verbatim · CDSS document, Apr 24, 2023 · control 21-AS-20230222133208

Type of visit: Office

The Department of Social Services (DSS) Community Care Licensing Division (CCL) Santa Rosa Regional Office held a meeting by virtual calling with the Department of Labor (DOL) and L & S Gentle Care II on 04/19/2023. The purpose of the meeting was to discuss the most recent findings from the DOL investigation of L & S Gentle Care II facility. Present in the meeting were: Department of Labor (DOL) Wage & Hour Division (WHD): Investigators Patricia Canites and Michael DeLaTorre. Department of Social Services (DSS) Community Care Licensing Division (CCL): Regional Manager Carla Nuti-Martinez, Licensing Program Manager Kim Mota, and Licensing Program Analyst Karina Canela. Licensee Imelda Padama and Licensee/Administrator Samuel Padama. DSS CCL to schedule a Non-Compliance Conference (NCC) with L & S Gentle Care II facility No citations issued at this time *A copy of this report was emailed to Administrator; signature in file.the state’s words, verbatim · CDSS document, Apr 19, 2023

Type of visit: Office

The Santa Rosa Regional Office conducted an informal meeting today 01/25/2023 by virtual calling with L & S Gentle Care II. Present in the meeting were: Licensing Program Manager Hope DeBenedetti, Licensing Program Analyst Karina Canela, LPA Katrina Walters, Licensee and Administrator Samuel Padama, and Licensee Imelda Padama. The purpose of the informal office meeting was to discuss areas of concerns with L & S Gentle care II facility. Items addressed during the meeting include, but are not limited to, areas: Previous compliance with California Title 22 Regulations and Community Care Licensing (CCL) Requirements Labor concerns Previous concerns during complaint investigation and case management visits, which were corrected No citations issued at this time *A copy of this report was emailed to Administrator; signature in file.the state’s words, verbatim · CDSS document, Jan 25, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Imelda Padama, Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA toured the facility and observed 6 residents in care. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). LPA reviewed records and conducted a spot check of resident medication. Fire extinguisher was charged and and serviced 03/15/2022. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings; grab bars, non-slip mat, liquid hand soap and paper towels available in bathrooms. During this visit, LPA verified staff vaccination records for COVID-19. LPA discussed the following requirements with Imelda Padama: · Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement) - Technical Advisory Note was issued to the facility during this visit. LPA requested the following updated forms to be submitted to Community Care Licensing by 07/13/2022: 1) LIC 308 Designation of Facility Responsibility (1 person per form); 2) LIC 500 Personnel Report; 3) LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents); 4) Copy of Liability Insurance; 5) LIC 610E Emergency Disaster Plan; 6) LIC 9020 Register of Facility Residents; 7) Copy of current Administrator's Certificate; 8) Copy of current Lease/Rental Agreement or Property Tax document showing control of property; Reminder: Facility Infection Control Plan due 06/30/2022 Report continued on LIC 809-D... LPA observed R1 who requires oxygen administration and requested S1 to turn off and remove oxygen being administered. This is a restricted health condition. Per regulation: 87618 Oxygen Administration - Gas and Liquid (a)Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances: (1) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself. OR (2) If intermittent oxygen administration is performed by an appropriately skilled professional. During inspection dated 06/02/2022, LPA observed R1 receiving oxygen administration and R1 stated they are unable to independently operate the equipment. Licensee stated facility staff assist R1 with their oxygen and R1's Home Health comes to the facility 2 times per week. LPA stated the facility staff must have an appropriately skilled professional assist R1 per regulation. R1's LIC 602 indicates R1 requires assistance to administer oxygen. Facility to request an exception for R1 from Community Care Licensing. LPA will review and return to issue citations if warranted regarding R1. The following deficiencies are being addressed during this inspection: · Reporting Requirements: During inspection dated 06/02/2022 LPA reminded facility and requested an Incident Report to be submitted for Resident (R1)'s hospital visit dated 05/24/2022. Licensee stated they would submit to CCL, but as of today's inspection CCL has not received it. The facility was previously cited for reporting requirements on 06/02/2022 * · Incidental Medical: During inspection of resident's medications on 06/28/2022, it was revealed staff crush resident (R2)'s medication. The facility does not have an order from R2's medical physician to crush medication. Appeal Rights Provided. * a Civil Penalty was issued in the amount of $250 for a repeat violation 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.the state’s words, verbatim · CDSS document, Jun 28, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jun 29, 2022

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical…(5)…Assistance with self-administered medications...(D)...does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section above due to R2 being given their medication crushed up, but does not have a crush order from the doctor (licensee stated R1 spits the pill out) which is an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Jun 28, 2022

Plan of correction: Administrator to have all staff trained on regulation 87465 and submit medication training documentation (with date, time, duration, subject, attendee's names and signatures) to Community Care Licensing (CCL) by 07/13/2022 attention LPA Karina Canela

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Jul 13, 2022

87211 Reporting Requirements: (a) Each licensee shall furnish...:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(B) Any serious injury...occurring while the resident is under facility supervision. This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure ensure the section above due to not notifying CCL of R1's hospital visit and Restricted health condition (oxygen administraton) as required. This is a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 28, 2022

Plan of correction: ***A civil penalty was assessed today in the amount of $250 for a repeat violation

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to provide adequate supervision resulting in resident sustaining pressure injuries Staff did not follow resident's care plan Staff did not inform resident's authorized representative of resident injuries Staff failed to seek timely medical

Licensing Program Analyst (LPA) K. Canela arrived at L & S Gentle Care II for the purpose of delivering findings on complaint # 21-AS-20220228080816. LPA met with Imelda Padama, Licensee. LPA investigated the above allegations. During the investigation, LPA conducted interviews, reviewed the facility file, inspected the facility, obtained and reviewed records. Report continued on LIC 9099-C Substantiated Allegation: Staff failed to provide adequate supervision resulting in resident sustaining pressure injuries: It was reported to Community Care Licensing that on 02/28/2022 the facility notified Resident (R1)’s responsible party of pressure injuries on R1’s feet. On 02/24/2022 Home Health indicated R1 developed: one stage III pressure injury, one un-stageable deep tissue injury and one intact blister. Interviews conducted revealed, R1’s wounds were quite deep and were likely not to have developed within one or two days, staff should have observed the initial start of the wounds if they had provided adequate supervision. In addition, interviews with relevant parties indicated such injuries would not have resulted on R1, if staff were to have given R1 proper body positioning. As a result of resident (R1)'s injury, the violation warrants a civil penalty assessment based on Health & Safety Code 1569.49(f). At this time, the civil penalty assessment is under review. Allegation: Staff did not follow resident's care plan: Review of facility records revealed a lack of required documentation to ensure R1’s care plan to meet their needs. Administrator did not do a proper pre-assessment of R1 prior to admitting R1 to L & S Gentle Care II. R1 is a 2-3 person assist and the facility did not have the proper fire clearance approval to admit or retain R1 due to their ambulatory status. Allegation: Staff did not inform resident's authorized representative of resident injuries: It was reported staff did not inform resident (R1)'s authorized representative of an incident. The unreported incident resulted in R1 sustaining a contusion on their lip and resulted in R1 needing oral surgery. Interviews with relevant parties indicated R1's lip contusion resulted from a fall or direct hit to R1's mouth. Staff interviews stated they were unaware if R1 sustained any falls or direct hit to R1's face that resulted in a contusion and oral surgery. Staff failed to seek timely medical: It was reported staff did not seek timely medical attention after R1 sustained an injury resulting in a contusion on their lip and oral surgery. Staff statements indicate they did not witness if R1 fell or that they were hit on the mouth. Interviews with relevant parties indicated R1's lip contusion resulted from a fall or direct hit to R1's mouth. R1's medical records indicate R1 was non-ambulatory at the time, was not able to walk independently and requires a 2-3 person assist. Staff statements indicated they notified R1's representative when R1 was found chewing on one of their teeth. Staff statements indicated they believed R1's tooth "just fell out" on its own. Staff then notified R1's representative, however staff did not seek medical assistance for R1's contusion. Report continued on LIC9099-C Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations were found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6), are being cited on the attached LIC 9099-D pages. Appeal Rights Provided. Deficiencies cited from the California Code of Regulations, (Title 22, Division 6) on the attached LIC9099-D pages. 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.the state’s words, verbatim · CDSS document, Jun 2, 2022 · control 21-AS-20220228080816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jun 8, 2022

87456 Evaluation of Suitability for Admission: (a)Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall...(2) Perform a pre-admission appraisal. This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure Resident (R1) was properly assessed with a pre-admission appraisal as required. This is a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Administrator to submit a written statement that they understand the regulation 87465(a)(2) 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jun 8, 2022

87211 Reporting Requirements: (a) Each licensee shall furnish...:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(B) Any serious injury...occurring while the resident is under facility supervision. This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure ensure both R1's responsible person and Licensing were notified of R1's injury to mouth/teeth and pressure injuries within the timeframe as required. This is a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Administrator to submit a written statement that they understand the regulation 87211(a)(1)(B) 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

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jun 3, 2022

§1569.269 Enumerated rights; severability: (a) Residents...shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff... to meet their needs. This requirement was not met as evidenced by: Based on record review and interviews conducted: Facility staff failed to ensure R1 received medical services in a timely manner after R1 sustained an injury to their mouth & pressure injuries (one stage 3). This is an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Administrator to submit a statement that they understand Health & Safety Code 1569.269(a)(6) and shall be in future compliance to meet the needs of residents in care. 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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 3, 2022

87466 Observation of the Resident : The licensee shall ensure that residents are regularly observed for changes in physical... functioning and that appropriate assistance is provided when such observation reveals unmet needs... (continued --->) Based on record review and interviews conducted: Facility staff failed to ensure proper care & supervision for R1 which resulted in R1 sustaining a stage 3 pressure injury. This is an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: (continued) ...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person...This requirement was not met as evidenced by: Administrator to submit a statement that they understand regulation 87466 and shall be in future compliance ensuring residents are are regularly observed for changes. 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

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Jun 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Jun 3, 2022

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: 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.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(a) · Plan of correction due date: Jun 8, 2022

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: 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.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.1(a)(11) · Plan of correction due date: Jun 8, 2022

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. 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.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: 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. 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

Type of visit: Case Management - Deficiencies

Page 1 of 4 Licensing Program Analyst (LPA) Karina Canela arrived unannounced at L & S Gentle Care II on 05/23/2022 for the purpose of addressing a deficiency. LPA met with Individual (I1); Sam Padama, Licensee and Administrator; Imelda Padama, licensee arrived later. Fire Clearance Violation: On 05/13/2021, 778 Appaloosa Ct Fairfield CA, 94533 (Prior to being licensed) was approved for six (6) ambulatory (total capacity 6) from the Fairfield Fire Department. On 07/09/2021, LPA conducted the facility pre-licensing inspection during which LPA advised the licensee to request a fire clearance inspection for approval to accept and retain non-ambulatory and/or bedridden residents. Licensee Samuel Padama requested from Community Care Licensing (CCL) approval for four (4) non-ambulatory and two (2) bedridden for a total capacity of six (6) from the Fairfield Fire Department. The request was sent to the Fire Dept. on 07/21/2021. Licensee later notified CCL on 10/05/2021 that the fire clearance inspection was not scheduled yet and Licensee attempted to schedule it. On 02/28/2022, LPA observed residents with an ambulatory status of non-ambulatory and bedridden in care at L & S Gentle Care II. LPA requested the facility immediately request a fire clearance request for non-ambulatory and bedridden ambulatory status. On 03/22/2022, a fire clearance request was resubmitted for four (4) non-ambulatory and two (2) bedridden for a total capacity of six (6) from the Fairfield Fire Department. Report continued on LIC809-C... Page 2 of 4 On 04/05/2022, LPA inquired with Licensee Sam Padama after the outcome status of the fire clearance request. Sam stated he decided not to go through with the request for the updated fire clearance because he no longer wanted to continue with the request for bedridden because the facility would need to install a fire door in the hallway to the residents room and it is narrow; Sam did not agree and had safety concerns. On 04/06/2022, LPA sent Licensee an email warning with a copy of the facility license highlighted showing they are only approved for only 6 Ambulatory and regulation 87204 Limitations - Capacity and Ambulatory Status: 87204(b) "Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents." LPA stated the facility needed to immediately request approval to accept and retain non-ambulatory residents since the facility had non-ambulatory residents in care without the proper fire clearance approval, to avoid a civil penalty and citation. On 04/12/2022, a fire clearance inspection was requested for six (6) non-ambulatory (for a total capacity of 6) On 05/17/2022, LPA verified with the Fairfield Fire Department that L & S Gentle Care II was not approved to accept or retain non-ambulatory residents. LPA was notified that Licensee Sam Padama declined to continue with fire clearance approval for non-ambulatory ambulatory status. Fire Inspector stated Licensee backed out of the fire clearance request about 2-3 weeks ago and instructed licensee to notify CCL. On 05/19/2022, Licensee explained over the phone that they no longer wanted to continue with requesting approval for non-ambulatory clearance due to disagreeing with the fire department's requirements such as installing a fire protected door in the bedroom hallway since the hallway is "too narrow" and Licensee was unsure resident's wheelchairs would be able to safely fit through the hallway if a fire door was installed. *LPA reiterated the warning sent on 04/06/2022 and that the facility is required to comply with the local Fire Department's requirements in order to accept or retain non-ambulatory (and/or bedridden) residents. Licensee stated he would contact the fire department to schedule another fire clearance inspection. *** As of 05/23/2022, the facility has 4 residents in care (R1 - R4) with a non-ambulatory status and 2 residents (R5 & R6) with diagnosis of Dementia (with ambulatory status). LPA requested the facility have R5 & R6 re-evaluated to confirm their ambulatory status and consider their mental condition. Report continued on LIC 809-C.. Page 3 of 4 Non-Associated Individual Violation: Additionally during today's inspection, LPA observed Individual (I1) working and providing care to residents in the facility. It was revealed I1 had begun working at the facility since 05/01/2022. LPA confirmed with the facility's personnel roster printed 05/23/2022 that I1 is not associated to L & S Gentle Care II. LPA confirmed with Community Care Licensing on 05/23/2022 through Guardian, that I1 is finger print cleared but not associated as required. (*LPA sent Licensee a copy of their facility staff roster on 04/28/2022 via email with a list of associated staff, I1 was not on the list.) Licensee Sam Padama arrived later and stated I1 is fingerprint cleared and associated to sister facility L & S Gentle Care (located in Vacaville, CA). Licensee stated their office has had difficulty associating I1 and I1 was re-fingerprinted on 05/02/2022. LPA explained prior to anyone working (including waiting for association, 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. * LPA provided the forms to associate individual (I1) to licensee Imelda Padama during this inspection. 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. Dementia Program Care Plan Violation: During today's inspection, LPA verified with the facility's file and Licensee that the facility does not have approval for a Dementia Program Care Plan and does not have one on file. Licensee stated they originally submitted a Dementia Care Plan with their application, however he notified the Centralized Application Bureau that the Licensee no longer wanted to continue with approval for a Dementia Program Care Plan since they would not accept or retain residents with a diagnosis of dementia. Licensee explained the facility planned to accept only residents with Mild Cognitive Impairment (MCI). LPA verified on 05/23/2022 that R4, R5, & R6 have a diagnosis of Dementia. LPA provided a copy of regulation 87705 Care of Persons with Dementia - 87705(c)(1) Report continued on LIC809 - C.. Page 4 of 4 Immediate Civil Penalties in the total amount of $1,250 were assessed today: $500 for a fire clearance violation. $500 for an non-associated individual. $250 for a repeated violation of an non-associated individual present at the facility. Appeal Rights Provided. Deficiencies cited (see LIC809-D page) 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.the state’s words, verbatim · CDSS document, May 23, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(1) · Plan of correction due date: May 24, 2022

87202 Fire Clearance:(a) All facilities shall ...Prior to accepting or retaining any of the following types of persons...obtain an appropriate fire clearance approved by the city...fire department...(1) Nonambulatory persons. This requirement was not met as evidenced by: Based on observation, interviews, and record review - Administrator did not ensure the regulation above due to having 4 non-ambulatory residents (R1-R4) in bedrooms that are not approved for non-ambulatory residents. This is an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, May 23, 2022

Plan of correction: Administrator to submit a statement that they understand the regulation and shall be in future compliance. Administrator to request a fire clearance inspection for non-ambulatory and/or bedridden from CCL and submit the required documents by POC due date 05/24/2022 to CCL *** An immediate Civil Penalty in the amount of $500 was assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e)(2) · Plan of correction due date: May 24, 2022

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: Based on record review, observation, and interviews conducted: Administrator did not associate individual (I1) prior to working, residing or being present in the facility. This is a potential safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 23, 2022

Plan of correction: Administrator to associate I1 as required. Administrator to submit a written statement they understand the requirement and will be in future compliance with the regulation by POC due date 05/24/2022 to Community Care Licensing **Civil Penalties assessed in the amount of $500.00 for non-associated individual working and $250 for repeated violation

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(c) · Plan of correction due date: May 30, 2022

87208 Plan of Operation: (c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by: Based on record review, observation, and interviews conducted: Administrator did not ensure the regulation above due to not having an approved dementia program care plan prior to accepting and retaining residents with a diagnosis of dementia. This is a potential safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 23, 2022

Plan of correction: Administrator to submit a statement that they understand the regulation, will be in compliance, and not accept any additonal residents with diagnosis of dementia. Administrator to submit their a copy of their dementia program plan for their facility file. POC due date 05/27/2022 by close of business, 5 PM.

Type of visit: Post Licensing

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 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 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 03/08/2022the state’s words, verbatim · CDSS document, Mar 1, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 2, 2022

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: 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.the state’s words, verbatim · CDSS document, Mar 1, 2022

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e)(2) · Plan of correction due date: Mar 8, 2022

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: 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.the state’s words, verbatim · CDSS document, Mar 1, 2022

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(1) · Plan of correction due date: Mar 8, 2022

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... 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.the state’s words, verbatim · CDSS document, Mar 1, 2022

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Mar 8, 2022

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. 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.the state’s words, verbatim · CDSS document, Mar 1, 2022

Plan of correction: 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. Licensee to submit an exception request, physician perscription, and supporting documents to CCL to clear the citation by POC due date 03/08/2022

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Karina Canela and Jill Nakagawa conducted a pre-licensing inspection on 07/09/2021. LPAs met with Applicants Samuel and Imelda Padama, who will be the Administrator when the facility is approved for licensure. The facility has a dementia care plan and has submitted a hospice waiver request for 2 residents. The facility has a fire clearance approval from the Fairfield Fire Department for 6 ambulatory residents for a total capacity of 6. Applicant stated they will request an updated fire clearance for 6 non-ambulatory residents. Facility will operate with a 24 hour staffing and Licensee will ensure sufficient staffing at all times. During today’s visit LPAs observed the following items: · COVID-19 postings and screening station at entrance · Lockable separate cabinets for medications, toxin, and knives. · All exits were unobstructed · 7 smoke detectors, 1 combination smoke and carbon monoxide detector and 1 carbon monoxide detector, which were tested and observed to be operational · First Aid kit, night-lights, and flashlights for emergency lighting · 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 2 of 6 resident bedrooms · A shed in the backyard used for storage · Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy). Report continued on LIC 809-C. During today’s visit LPAs observed the following items: · Chest of drawer needed in bedrooms 3, 4, 5, and 6. Applicant stated they would purchase 4 chest of drawers a minimum of 8 cubic feet per regulation and would send pictures as proof to LPA. · 1 charged fire extinguisher without a service tag. Applicant stated it was a new purchase and would send a copy of the receipt. Pre-licensing is incomplete with corrections needed for the following items to proceed with licensure. · Required furnishings · Receipt for purchase of new fire extinguisher The Component III Orientation was completed during today's inspection. Pre-Licensing is incomplete with above items to be resolved by 7/12/2021. Applicant to submit pictures as proof of correction to Community Care Licensing Department (CCLD) for review. Once corrections are submitted and reviewed by CCLD, LPA will submit the pre-licensing report with proof of corrections to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.the state’s words, verbatim · CDSS document, Jul 9, 2021