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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002685
Report Date: 09/04/2021
Date Signed: 09/04/2021 08:53:04 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: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: 34DATE:
09/04/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
07:15 PM
MET WITH:J. YoungTIME COMPLETED:
08:45 PM
NARRATIVE
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LPA Albert Johnson conducted a case management visit on today's date met with Jami Young.

This visit for a Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. As a result of this visit LPA determined that the facility did not report additional positive residents or staff as required and the facility does have a mitigation plan in place that needs to be reviewed and revised.

LPA is requesting the following by 9/7/2021 by close of business:

Mitigation plan and a staffing schedule for the month of September.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Report given with appeal rights.

Exit interview conducted.


SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2021
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
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: 09/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2021
Section Cited

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87211(a)(2) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate
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This requirement is not met as evidenced by: Based on the observation interview, LPA observed no incident reports for positive Residents and Staff which pose a health 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2021
LIC809 (FAS) - (06/04)
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