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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700061
Report Date: 12/20/2022
Date Signed: 12/20/2022 10:03:46 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/20/2022 10:03 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
SACRAMENTO AC/SC, 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:
12/20/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:MOFOR, JANETIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's were met by Administrator . LPA were screened upon entry for COVID precautions. LPA's explained the purpose of the visit to Administrator. Administrator's Certificate # 6047363735 Expires 06/12/2022. Administer said "she is doing the class now and will submit the paperwork by 12/21/2022.

LPA and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 0. There is entry door is leading to the living room, kitchen with a stairway to bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to have a place to be locked to residents in care.

Hot water temperature was measured at 110 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SAINT PETERS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 392700061
VISIT DATE: 12/20/2022
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LPA's observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA's observed, fire extinguishers inspected on 12/12/2022 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA did not review any staff or resident files. LPA observed there are no residents at this time.



Exit interview held with staff and copies of reports left at conclusion of visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2