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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200803
Report Date: 03/21/2024
Date Signed: 03/21/2024 11:30:01 AM

Document Has Been Signed on 03/21/2024 11:30 AM - 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 IFACILITY NUMBER:
079200803
ADMINISTRATOR:JO, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:1107 METTEN AVETELEPHONE:
(925) 594-2003
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Warren Garibay, Direct Support ProfessionalTIME COMPLETED:
11:40 AM
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On 3/21/2024 at 9:40am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Warren Garibay, Direct Support Professional (DSP), and explained the purpose of the visit. Administrator, Christopher Jo, arrived at 10:23am. The administrator currently holds a certificate (#6050227735) that expires on 11/15/2024. The facility’s fire clearance was approved for two (2) ambulatory and four (4) non-ambulatory clients. Three (3) clients were attending day program.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of six (6) bedrooms and two (2) bathrooms. One (1) bedroom occupied by staff. Bedroom in garage fire cleared and occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 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 121.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 03/21/2024
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan last updated on 1/4/2022. Fire extinguisher was last serviced on 06/6/2023. Fire drill last conducted 2/29/2024. First aid kit was observed to be complete.

Four (4) staff records were reviewed, and all current and complete. All five (5) clients' records reviewed, current, and complete. LPA reviewed P & I and a sample of clients' medication.

The following forms to be updated and submitted to CCLD by 3/28/2024:
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • LIC610D (Emergency disaster plan) last page only


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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