<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500301453
Report Date: 04/05/2024
Date Signed: 04/18/2024 03:39:56 PM


Document Has Been Signed on 04/18/2024 03:39 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/18/2024 02:41 PM

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

NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This report is being amended to complete the visit for 04/05/24 to update the original date recorded, the POC and correct verbiage.

On 04/05/24 Licensing Program Analyst, (LPA) Renee Campbell made an unannounced case management visit to this facility. This visit was prompted by a fax from the Assisted Living Director (ALD), Melina Nunez who notified Community Care Licensing (CCL) about an alleged case of verbal abuse. LPA Campbell identified herself upon arrival and asked to speak with the ALD. LPA Campbell met with Melina Nunez, who is the Assisted Living Director and the Designated Facility Administrator and a brief interview followed.

Over the course of the investigation, LPA Campbell interviewed staff and reviewed the report from the reporting party. Staff reported that S1 used an elevated volume and inappropriate tone with R1. Staff interviewed did not report abusive language was used.

Based on interviews with W4, S3, S1, S2, W2 and W3, LPA Campbell found that there was a preponderance of evidence to support a violation of personal rights.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, a Type B deficiency is being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights.



An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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


Document Has Been Signed on 04/18/2024 03:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/18/2024 02:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TURLOCK
FACILITY NUMBER: 500301453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
87468.1(a)(1)

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents ...: (a) Residents in ... care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff,..., and other persons. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will create an in-service training for all staff on dignity and respect. A copy of the in-service itinerary and sign in sheet will be provided to LPA Campbell by POC date that will be emailed to
renee.campbell@dss.ca.gov
8
9
10
11
12
13
14
Based on interviews with W4, S3, S1, S2, W2 and W3, the licensee did not ensure residents were accorded dignity to residents in residential care facilities.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2