079200803-3-7-2023-15-AS-LHAL-CPQ3VH-20230307173509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200803
Report Date: 03/07/2023
Date Signed: 03/07/2023 05:35:20 PM

Document Has Been Signed on 03/07/2023 05:35 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ST FRANCIS HOME I		FACILITY NUMBER:	079200803
ADMINISTRATOR:	JO, ROBERT		FACILITY TYPE:	735
ADDRESS:	1107 METTEN AVE		TELEPHONE:	(925) 594-2003
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY: 6		CENSUS: 6	DATE:	03/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Warren Garibay, Direct Support Professional		TIME COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/7/2023 at 01:50PM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler conducted an unannounced annual required inspection. LPA met with Warren Garibay, Direct Support Professional (DSP), and explained the purpose of the visit. LPAs toured the facility with DSP, Warren Garibay. Co-Administrator, Christopher Jo, arrived at 2:45PM. The facility’s fire clearance was approved for two (2) ambulatory and four (4) non-ambulatory clients. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) total bedrooms which two (2) are occupied by the staff. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 119.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. PPE and paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods. Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST FRANCIS HOME I	FACILITY NUMBER: 079200803
	VISIT DATE: 03/07/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued on LIC809C.

Fire extinguisher was last serviced on 6/1/2022. Emergency Disaster Plan was last posted on 06/06/2022. First aid kit was observed to be complete. Fire drill was last conducted on 2/25/2023.

Five (5) staff records were reviewed, and all staff have criminal record clearance, first-aid, and CPR. All six (6) clients records reviewed and were complete.

The following forms to be updated and submitted to CCLD by 03/14/2023:

LIC 500 Personnel Report
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
Administrator certificated.

LPA observed the following deficiencies:

At 2:20PM, LPAs observed wooden boards with nails, ceramic tile, a ladder, a lawn mower, 3 wheelchairs, a commode, a shower chair, 2 clothes racks, a walker and trash located on left side and on deck behind house.
At 3:35PM, LPAs observed three (3) of six (6) clients are over the age of 59 and facility does not have an age exemption.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/07/2023 05:35 PM - It Cannot Be Edited

Created By: Laura Hall On 03/07/2023 at 05:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST FRANCIS HOME I	FACILITY NUMBER: 079200803
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having outdoor passageways and patio cleared which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2023
	Plan of Correction
1 2 3 4	Co-Administrator agreed to have all debris removed and submit a photo to CCLD by POC date.

Type B

Section Cited

CCR

85068.4

85068.4 Acceptance and Retention Limitations (g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on(observation, interview, and record review, the licensee did not comply with the section cited above in have an age exemption for C2, C3, and C4 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2023
	Plan of Correction
1 2 3 4	Co-Administrator agreed to submit a request for an age exemption for C2, C3, and C4, and submit request to CCLD by POC date.

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:

Harpreet Humpal

LICENSING EVALUATOR NAME:

Laura Hall

LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3