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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000306
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:53:21 PM


Document Has Been Signed on 05/02/2024 03:53 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 CARE-TURLOCK RESIDENTIALFACILITY NUMBER:
507000306
ADMINISTRATOR:RUTH VILLARREALFACILITY TYPE:
740
ADDRESS:1101 E. TUOLUMNE ROADTELEPHONE:
(209) 667-8409
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY:49CENSUS: 44DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Warkentin, Executive DirectorTIME COMPLETED:
04:00 PM
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On 05/02/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced at approximately 8:30 am to conduct an annual inspection. LPA Campbell met with Executive Director, Jennifer Warkentin and stated the purpose of the visit. LPA Campbell inspected the physical plant to ensure compliance with Title 22 regulations. The administrator's certificate # is 7024856740. This number's expiration date is pending due to administrator renewal backlogs. The current census is 44 residents with 25 staff.

The facility is a one floor building licensed to service adults age 60 and over. The facility may accept up to 49 ambulatory and non-ambulatory residents of which 2 may be hospice. No body of water was found. Upon entry, LPA Campbell observed several residents in wheelchairs sitting by the door without socializing. A glass window lead into the administrators office. A male guest was signing into the guest book.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, laundry room and outside areas of the facility to ensure compliance with Title 22 regulations. Resident rooms have individual patios. that lead to the front of the parking lot or surrounding facility driveway. The facility was observed to be free of odor and in good repair.

While touring the facility, LPA Campbell observed the thermostat was set at 74 degrees Fahrenheit. When entering the medication room, LPA Campbell was able to observe the online MAR system that recorded medication dispensation, initialed by staff.



SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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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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 CARE-TURLOCK RESIDENTIAL
FACILITY NUMBER: 507000306
VISIT DATE: 05/02/2024
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 First aid kits were verified as having bandages, scissors, tweezers and thermometers as well as a manual. A laundry room was also observed while staff washed resident items.

LPA Campbell entered the kitchen and observed two staff preparing for lunch. A freezer was filled top to bottom after a recent shopping trip per the administrator.. The freezer temperature was -5 degrees Fahrenheit which meets the maximum requirement of 0 degrees Fahrenheit. The refrigerator temperature was 34 degrees Fahrenheit and below the required maximum of 40 degrees Fahrenheit and it contained enough perishable food for residents for two days. LPA Campbell observed a covered cake cooling in the food pantry and un-expired milk in the refrigerator. There were a variety of non-perishable foods in the pantry to last the residents 7 days.

The hot water temperature was measured in the resident bathroom at 105 degrees Fahrenheit which is within the required maximum range of 105 to 125 degrees Fahrenheit. The fire extinguishers were last inspected on 06/01/2023.  There were no changes to the building layout since the most recent floor plan. Due to technical difficulties, the facility was unable to verify that staff had 1st Aid or CPR certification. Facility will provide 1st Aid Staff training report by 05/06/24.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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