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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600905
Report Date: 08/04/2020
Date Signed: 08/04/2020 01:19:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ST. FRANCIS HOMEFACILITY NUMBER:
300600905
ADMINISTRATOR:SR IRMA PADILLAFACILITY TYPE:
740
ADDRESS:1718 WEST SIXTH STREETTELEPHONE:
(714) 542-0381
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY:90CENSUS: 24DATE:
08/04/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Veronica VillalbandoTIME COMPLETED:
12:30 PM
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Licensing Program Manager (LPM) Marina Stanic and Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of conducting a case management visit. During today’s visit, LPM and LPA met with Sister Maria De La Luz Acosta and Skilled Management Inc. representatives Adam Zeno, Mochi Berc and Lisa Pham and explained the reason for the visit.

During today's visit, LPM and LPA met with Skilled Management Inc. and Sisters Veronica Villalbando, Maria De La Luz Acosta, Celena Rojas and Irma Padilla in order to transition from Skilled Management Inc. to the Licensee in order to resuming the operation of the facility. It was determined that all 36 resident records and medication records are complete and accounted for. In addition the facility has ample food and PPE's supplies. The Licensee obtained keys to the facility.

The cancellation of the contract 19-3113 termination has been emailed to to Adam Zeno and the management company has successfully transition out at 12:30pm. The sister were successfully transition over to resume operations. Skilled Management Inc agrees to deliver the gate controller and a main entrance key by August 20, 2020.

An exit interview was conducted and a copy of this report was provided to facility representatives.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020
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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