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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002685
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:58:37 PM


Document Has Been Signed on 11/02/2023 01:58 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 AC/SC, 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:
2096688014
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY:56CENSUS: 41DATE:
11/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dawn Ell, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced to conduct a case management visit on November 2, 2023 at 10:00 AM and explained the purpose of the visit. LPA Campbell met with Care Coordinator Dawn Pero and Administrator Nicole Ell arrived 15 minutes later.

The purpose of the visit today, is in response to follow up on an elopment that occurred on October 25, 2023. It was learned resident 1 (R1) successfully left the facility unattended at 5:45 PM, and the Turlock Police Department returned R1 to St. Francis Assisted Care facility at 6:45 PM. An immediate $500.00 civil penalty shall be assessed on November 02, 2023 due to lack of care and supervision and an immediate health and safety risk to R1. R1's LIC 602 Health Certification Form indicates, they are not able to leave the facility unattended and indicates R1 has Alzheimer’s Dementia. In addition, R1 is not to leave the facility unassisted.

Additionally, when arriving to the facility, LPA Campbell observed a sign with the pending new name of the facility on the building. LPA Campbell spoke with Care Coordinator Dawn Pero and Administrator Nicole Ell and reminded them that because the facility has not yet been licensed, the new name therefore cannot be used in any advertisements. This includes new signage and admission agreements. During today's visit, Facility Coordinator, Albert Cardenas covered one of the two signs with a tarp. The remaining sign will be covered by Monday, November 6, 2023.

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.


If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be further assessed. The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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 2


Document Has Been Signed on 11/02/2023 01:58 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 AC/SC, 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: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
HSC
1569.312(d)

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HSC - 1569.312(d) Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, ...This requirement is not met as evidence by:
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Licensee agrees to create a plan that will address pedestrian traffic at the drive in gate and update the pre-assessment to address elopement prior to admission by POC date 11/09/23.
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Based on incident report, the facility did not comply with section cited above when R1 eloped from facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident 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: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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