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Inspection visit

Follow-up on corrections

L & S GENTLE CARE IILicense 4868039743 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

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.

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 other inspection of L & S GENTLE CARE II on June 2, 2022. 3 citations were issued: 1 Type A (serious) and 2 Type B.

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

Yes, 3 citations were issued (1 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 other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

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