507002685-10-30-2020-27-AS-CACL-BUVSBK-20201030134404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507002685
Report Date: 10/30/2020
Date Signed: 10/30/2020 09:29:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200824120524

FACILITY NAME:	ST. FRANCIS ASSISTED CARE		FACILITY NUMBER:	507002685
ADMINISTRATOR:	JAMI YOUNG		FACILITY TYPE:	740
ADDRESS:	120 20TH CENTURY BOULEVARD		TELEPHONE:	(209) 668-8014
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95380
CAPACITY:	56	CENSUS: 42	DATE:	10/30/2020
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jami Young		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Lack of supervision resulted in resident on resident assault.
Facility staff did not seek timely medical attention for resident.
Staff not properly trained to assist during residents emergency.
Staff not providing adequate supervision of inappropriate resident behavior.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver complaint findings on 10/29/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the investigation findings with Jami Young.

Throughout the course of the investigation, the Department conducted interviews, reviewed facility documents, and reviewed a surveillance video. Based on the investigation, the following allegations are unsubstantiated:

Lack of supervision resulted in resident on resident assault.
Facility staff did not seek timely medical attention for resident.
Staff not properly trained to assist during resident’s emergency.
Staff not providing adequate supervision of inappropriate resident behavior.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200824120524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. FRANCIS ASSISTED CARE	FACILITY NUMBER: 507002685
	VISIT DATE: 10/30/2020

NARRATIVE

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Based on hospital medical records, resident 1 was diagnosed with a 3 centimeter left lower quadrant abdominal stab wound with no active bleeding. It was also learned there was no indication resident 2 had a pocketknife. There was no indication resident 2 had an intention of stabbing resident 1. In addition, video footage captures resident 1 and resident 2 sitting at two different tables on the day of the incident. At the time of the incident, resident 2 got up from his table and walked over to resident 1 and proceeded to stab resident 1.

After the stabbing incident occurred, care staff responded in a timely manner. A medical response call was made at 1723 hours, and an ambulance arrived at the facility at 1728 hours. Furthermore, video footage captures a first aid certified care staff providing first aid to resident 1 after incident occurred. In addition too, care staff removing resident 2 away from resident 1. Moreover, the surveillance camera shows 4 care staff working in the dining room area, which they all provided care to residents during and after the stabbing incident. Additionally, resident 2 and resident 3 both stated they feel safe at the facility.

As a result of this investigation, the Department finds the allegations to be unsubstantiated. Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegation is unsubstantiated.

An exit interview was conducted with Jami Young and a copy of this report was provided to Jami Young via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC9099 (FAS) - (06/04)

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