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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002685
Report Date: 09/20/2023
Date Signed: 09/20/2023 02:54:31 PM


Document Has Been Signed on 09/20/2023 02:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ST. FRANCIS ASSISTED CAREFACILITY NUMBER:
507002685
ADMINISTRATOR:JAMI YOUNGFACILITY TYPE:
740
ADDRESS:120 TWENTIETH CENTURY BLVDTELEPHONE:
(209) 668-8014
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY:56CENSUS: 38DATE:
09/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Office Manager Dawn PeroTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to conduct a case management visit. LPA Lund met with Office Manager Dawn Pero and explained the reason for the visit.

LPA Lund reviewed Resident’s (R1) LIC602A dated 3/28/2022 stating that R1 ambulatory status is bedridden. The facility license (LIC203A) for St. Francis Assisted Care effective date 7/31/2006 doesn’t have a fire clearance granted for bedridden residents.

Deficiency was observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Civil Penalties issued and exit interview conducted with Office Manager Dawn Pero report given with appeal rights.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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Document Has Been Signed on 09/20/2023 02:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ST. FRANCIS ASSISTED CARE
FACILITY NUMBER: 507002685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2023
Section Cited
CCR
87202(a)(2)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons... (2) Bedridden persons.
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The resident moved out of the facility.
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Requirement has not been met as evidenced by: Records show the facility doesn’t have a fire clearance for bedridden residents. This poses 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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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