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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002685
Report Date: 09/22/2021
Date Signed: 03/29/2022 08:18:41 AM


Document Has Been Signed on 03/29/2022 08:18 AM - 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: 32DATE:
09/22/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Facility staff , Aimee Jo MattsonTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility to conduct an unannounced case management POC visit. LPA met with facility staff member Aimee Jo Mattson. LPA explained the purpose for today's visit. LPA has not received any documents to clear POC on several citations related to the Case Management COVID visit conducted on 09/10/2021. Facility staff has not received N95 mask fit testing, licensee has not submitted certification of understanding to LPA, and staff only completed donning and doffing training as of yesterday. LPA issued civil penalties for failure to correct these violations. LPA also issued civil penalties for failure to clear POC on a case management visit conducted on 09/17//2021. As of today Licensee has not hired an Administrator with a current Administrator's certificate.


An exit interview was conducted with facility staff and a copy of this report along with appeal rights was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
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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