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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500301453
Report Date: 05/24/2024
Date Signed: 05/24/2024 02:56:25 PM


Document Has Been Signed on 05/24/2024 02:56 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: 285DATE:
05/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Melina Nunez, Assisted Living DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 05/24/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannouncied to conduct a Case Management regarding an incident that occurred on 05/15/2024. LPA Campbell met with Melina Nunez, Assisted Living Director and explained the purpose of the visit.

On 05/15/24, the facility self-reported an incident regarding a resident (R1) who left the facility unassisted. Per R1's 602, they were not to leave the facility unassisted and were prone to wandering behavior. A neighbor saw R1 walking unassisted about 8 minutes away from the facility and notified facility staff. Staff 1 (S1) returned R1 to the facility and a medical evaluation was conducted by S2 for R1. The incident report was submitted to the Department the next day on 05/16/2024.

Per the Assisted Living Director, R1 was able to leave the facility because staff did not conduct a head count for Wander guard residents after the alarm signaled. Wander guard will alert if a resident is wearing one near the entrance. R1 was wearing a Wander guard. At the time of R1's elopement, there were several residents wearing Wander guard near the entrance. The residents were at the same entrance that R1 used to leave the facility and there was an alert. No staff verified the presence of all the Wander guard residents in the facility. Instead, staff assumed no residents had actually left the facility and were just at the entrance. The facility was unable to recount when R1 left the facility or for how long. R1's family was notified of the incident.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. 
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
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 3


Document Has Been Signed on 05/24/2024 02:56 PM - It Cannot Be Edited

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: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
HSC
1548(c)(3)

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1548 Civil penalties; regulations setting forth appeal procedures for deficiencies. (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation...for...(3) Absence of supervision, as required by statute or regulation. This requirement is not met as evidenced by:
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The facility will conduct an in service training for staff as well as agency staff regarding Wanderguard residents. Whenever the alarm sounds, a head count will be conducted for all Wande rguard residents and this procedure will be added to the policy procedure manual. The facility will provide the sign in sheet
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R1 was able to leave the facility unassissted and absenst of supervision, as required by statute or regulation and their 602. This poses an immediate Health, Safety and Personal Rights risk to persons in care.
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for the in-service training with signatures from both Covenant Living staff and agency staff.and will provide the updated page for the policy procedure manual regarding Wander guard head counts. All documentation will then be emailed to renee.campbell@dss.ca.gov by POC date.

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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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
VISIT DATE: 05/24/2024
NARRATIVE
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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: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3