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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500301453
Report Date: 11/22/2021
Date Signed: 11/22/2021 05:16:04 PM

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: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: DATE:
11/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Director Melina Nunez TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Case Management visit. LPA met with Director Melina Nunez and explained the reason for today’s visit. Community Care Licensing received an incident report indicating that resident #1 (R1) left the facility on 9/1/21.

On 11/22/21, LPA interviewed the Director Melina Nunez regarding the absence of R1.

Director Melina Nunez acknowledge the absence without Leave (AWOL). Upon a review of the most recent Physician Report (LIC602) dated 6/28/21, it indicates that R1 is not able to leave the facility unassisted.

The Unusual/Incident Report (LIC 624) dated 9/1/2021 stated that R1 removed the wonder guard prior to leaving the facility. R1 went out the back door of the facility and was found by staff approximately 45 minutes later in the neighborhood behind the facility. Turlock PD was called from a neighbor and arrived but didn’t file a police report of the incident. R1 has since got a bracelet that can be removed.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. You are hereby assessed an immediate civil penalty in the amount of $500.00.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Director Melina Nunez was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held with Director Melina Nunez and report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COVENANT LIVING OF TURLOCK
FACILITY NUMBER: 500301453
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2021
Section Cited

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87705 (k)(8) Care of Persons with Dementia.
Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.
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This requirement is not met as evidenced by: Resident (R1) was not accounted for. The facility activated all staff to locate R1. R1 was found 45 minutes behind the facility.
This an immediate Health, Safety or Personal Rights risk to residents in care.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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