Inspection visit

complaintJune 2, 2022

L & S GENTLE CARE IILicense 4868039744 citations on this visit

4 citations recorded

Inspector’s narrative

What the inspector wrote

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.

Citations

7 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

1569.269(a)(6)Type A
§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.
87211(a)(1)(B)Type B
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.
87465(a)(2)Type B
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.
87466Type A
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.
87224(a)Type B
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.
87468.1(a)(11)Type B
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.
87615(a)(1)Type A
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.

FAQ · About this visit

Common questions about this visit

What happened during the June 2, 2022 inspection of L & S GENTLE CARE II?

This was a complaint inspection of L & S GENTLE CARE II on June 2, 2022. 4 citations were issued: 2 Type A (serious) and 2 Type B.

Were any citations issued to L & S GENTLE CARE II on June 2, 2022?

Yes, 4 citations were issued (2 Type A, 2 Type B). The first citation was for: "§1569.269 Enumerated rights; severability: (a) Residents...shall have all of the following rights: (6) To care, supervis..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·June 2, 2022