Facility Evaluation Report

A Subsequent Non-Compliance Meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio, and Licensee, Imelda Padema.

The purpose of the Subsequent Non-Compliance Meeting was to discuss areas of non-compliance and ongoing observed concerns during inspection on September 19, 2024, in the of the operation of L & S Gentle Care II, facility #486803974. Facility was placed on a Non-Compliance Plan on 07/13/2023 and received Technical Support Provider (TSP) consultations on 08/14/2023 and 08/28/2023. Today, the Licensee were informed that further and/or repeat citations may result in extending the facility’s non-compliance plan or possibly administrative action. The legal administrative action process was explained to attendees.

Items addressed in today's meeting include patterns of non-compliance in the following areas :

1. Fire Clearance/Live-in Staff : Staff shall not sleep or reside in un-permitted/uncleared rooms or facility communal areas, (see pictures). LPA Karina Canela cited for the same deficiency 07/10/2023 after numerous discussions regarding the same issue on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022.

2. Staffing : Staff must be sufficient in numbers to provide adequate care and supervision to residents in care.

3. Staff Training : Staff m ust complete initial training hours prior to working independently with residents.

4. Staff Medication Administration Training: Staff shall be complete initial training hours prior to working independently with residents.