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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200803
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:52:59 PM

Document Has Been Signed on 08/17/2022 02:52 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:JO, ROBERTFACILITY TYPE:
735
ADDRESS:1107 METTEN AVETELEPHONE:
(925) 594-2003
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Delores Garibay, CaregiverTIME COMPLETED:
03:05 PM
NARRATIVE
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On 8/17/2022 at 1:00PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an email received on 08/10/2022. LPA met with Delores Garibay, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Robert Jo via telephone. Administrator advised staff Christopher Jo will come to facility. Christopher Jo arrived at 1:55PM.

The email contained an updated sketch of the facility showing that a room was built in the garage for staff to have more privacy and to relax. The Administrator did not notify the Department of the alteration prior to the change or obtain a permit.

While conducting the case management LPA L. Hall observed staff S3 was not associated to facility. S2 stated that S3 was training and this was her first day.

An immediate civil penalty of $100.00 was assessed.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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
Document Has Been Signed on 08/17/2022 02:52 PM - It Cannot Be Edited


Created By: Laura Hall On 08/17/2022 at 01:14 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: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
CCR
80086(c)

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80086 Alterations to Existing Building or New Facilities (c) Prior to construction or alterations, ...law requires that all facilities secure a building permit. This requirement was not met as evidence by:
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Administrator agreed to submit a copy of a permit and LIC200 to CCLD by POC date.
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Based on LPA's observation and record reviewed the Licensee did not comply with the section cited above in obtaining a building permit prior to construction, which poses a potential health and safety risk to persons in care.
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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: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/17/2022 02:52 PM - It Cannot Be Edited


Created By: Laura Hall On 08/17/2022 at 02:12 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: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance (e)All individuals subject to a criminal record... shall prior to working... in a licensed facility: (1) Obtain a California clearance... as required by the Department This requirement was not as evidence by:
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Administrator agreed to submit a copy of S3's identification and LIC9182 to CCLD by POC date.
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Based on LPAs observation and record review the Licensee did not comply with the section cited above in having S3 having a criminal record clearance, which poses a potential health and safety risk to persons in care.
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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: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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