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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500301453
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:58:29 PM


Document Has Been Signed on 01/24/2024 12:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:COVENANT LIVING OF TURLOCKFACILITY NUMBER:
500301453
ADMINISTRATOR:RYAN HUSTFACILITY TYPE:
741
ADDRESS:2125 N OLIVE AVENUETELEPHONE:
(209) 632-9976
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:377CENSUS: 280DATE:
01/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ryan Hust, Executive DirectorTIME COMPLETED:
01:00 PM
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On 01/24/24, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to Covenant Village of Turlock at approximately 1000. LPA Campbell met with Ryan Hust, Executive Director and Brenda Pisacco, Campus Nurse.

During the visit, LPA Campbell observed the incident reported that was submitted on 01/16/24 regarding an incident that occurred on 01/13/24. LPA Campbell requested a Physician’s Report, hospital records and interviewed R1’s son who was their Durable Power of Attorney (DPOA). The physician’s report indicated that R1 was ambulatory and there was no cognitive decline or disorientation. R1’s son was contacted, and he confirmed that he requested that R1 not be sent to the hospital. Instead, the DPOA wanted to take the resident to the hospital himself. The incident report did not include that the DPOA was contacted and made this request. No deficiencies were cited on today's inspection.

Exit interview was conducted with Ryan Hust and copy of this report provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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