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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700061
Report Date: 11/18/2021
Date Signed: 11/19/2021 05:55:12 AM

Document Has Been Signed on 11/19/2021 05:55 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SAINT PETERS RESIDENTIAL CARE HOME LLCFACILITY NUMBER:
392700061
ADMINISTRATOR:MOFOR, JANEFACILITY TYPE:
735
ADDRESS:2108 CANBY OAK DRTELEPHONE:
(510) 472-3989
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 6CENSUS: 0DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Maryam Faall, AdminstratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived to conduct an unannounced Annual inspection on this date. LPA met with Facility Administrator Maryam Faall and Jane Mofor. They were informed of the purpose of the visit and assisted with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility has submitted a program design to the Regional Center and is in the process of being vendorized for a VMRC home. tTe facility will submit the approved program design to Licensing. Administrator's Certificate for Maryam is 6047363735, expires 6/12/22.

LPA toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. Smoke alarms were tested and were operable. Fire extinguisher was serviced in November 2021 and is in compliance. The facility has 4 client bedrooms and 2 Client bathrooms. Water was tested at 115.8 degrees. Physical plant deficiencies issued on the attached 9099D.

LPA observed the following posted in the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, and LIC 309 were requested to be submitted to Licensing within 30 days as needed.

Exit interview held with acting Administrator and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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Document Has Been Signed on 11/19/2021 05:55 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 11/18/2021 at 02:06 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SAINT PETERS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 392700061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed clutter in the garage, in one client bedroom, a closet and by the stairway in the home. Touch up painting is needed on doors and baseboards. An electrical socket plate in one bedroom is broken and facility needs shaded seating area for clients outside of the home.
POC Due Date: 12/20/2021
Plan of Correction
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Due within 30 days. LPA will reinspect
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021


LIC809 (FAS) - (06/04)
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