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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002708
Report Date: 12/07/2022
Date Signed: 12/08/2022 08:28:44 AM

Document Has Been Signed on 12/08/2022 08:28 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. CHARLES MANORFACILITY NUMBER:
507002708
ADMINISTRATOR:WOODRUFF, DORISFACILITY TYPE:
735
ADDRESS:3316 ST. ANN WAYTELEPHONE:
(209) 483-8725
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 4DATE:
12/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Oscar DayritTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/07/2022 at 2:30PM, Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced case management visit to this facility. LPA Pascua met with House Manager, Oscar Dayrit and explained the purpose of the visit. The purpose of this visit is in response to a complaint visit conducted on 12/07/2022 at 12:30pm.

Upon LPA arrival, LPA walked up to the facility front door and R1 opened the door. LPA Pascua asked to speak with a staff member and was told that the resident was here by themselves . LPA then asked if R1 notified any staff members that they would be alone in the house. R1 stated that he notified S1 in the morning. LPA Pascua asked that R1 close the door and go back inside while she made a phone call. LPA contacted Facility Designated Administrator, Doris Woodruff and explained to her that R1 was at the facility by themselves. It was learned during this interview that the facility has been having issues with R1 and asking to be home by themselves and that the facility currently has an upcoming meeting with R1's Service Coordinator. Shortly after, House Manager Oscar Dayrit and Staff Member, Fernanda arrived at the facility.

Based on LPA Observation and interviews, the following Deficiencies are being cited Per Title 22 Regulations.

An exit interview was conducted and a copy of this report, the 809D, and appeal rights were emailed to the Facility Designated Administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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 12/08/2022 08:28 AM - It Cannot Be Edited


Created By: Arielle Pascua On 12/08/2022 at 08:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ST. CHARLES MANOR
FACILITY NUMBER: 507002708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited
HSC
80078(a)

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80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met by:
Based on LPA Observation and Interview, the facility did not provide
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The Licensee has agree to submit a written plan on how the facility will provide adequate care and supervision for the residents in care. The licensee shall submit a plan to Licensing by POC date, 12/08/2022.
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proper supervision for R1. R1 was discovered to be left alone with no staff at the facility during the time of LPA's arrival.
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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 Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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