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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200803
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:58:38 PM

Document Has Been Signed on 02/13/2025 04:58 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 IFACILITY NUMBER:
079200803
ADMINISTRATOR/
DIRECTOR:		JO, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:1107 METTEN AVETELEPHONE:
(925) 594-2003
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Kimberly Burks, Direct Care SupportTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 2/13/2025 at 2:15pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Kimberly Burks, Direct Care Support, and explained the purpose of the visit. Administrator, Christopher Jo, arrived at 3:14pm. The administrator currently holds a certificate (#7017635735) that expires on 11/15/2026. 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, 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 69 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 133.1 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: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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: 02/13/2025
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Continued on LIC809C.

Fire extinguisher was last serviced on 6/4/2024. Emergency Disaster Plan was last posted on 03/22/2024. First aid kit was observed to be complete. Fire drill was last conducted on 12/19/2024.

Five (5) staff records were reviewed, one (1) file was incomplete, and one (1) was not available for review. LPA reviewed all five (5) client files and they were complete. P & I also reviewed.

The following forms to be updated and submitted to CCLD by 02/20/2025:
  • LIC 500 Personnel Report
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond

LPA observed the following deficiencies:
  • At 3:20PM, LPA observed during record review C1 and C2's records of accounts of cash resources was not accurate.
  • At 3:45PM, LPA observed during record review that S2 did not have a health screen and S6 file was not available for review.


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period 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: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2025 04:58 PM - It Cannot Be Edited


Created By: Laura Hall On 02/13/2025 at 04:39 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having an accurate ledger for C1 and C2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Administrator agreed to review cash records, correct ledger for C1 and C2, and submit to CCLD by POC date.
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having S2 health screen and S6 file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Administrator agreed for S2 to obtain a health screening and S6 file available at facility. Administrator will submit a copy of the health screening, and a self-certification for S6 file 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: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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