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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005360
Report Date: 12/17/2021
Date Signed: 12/17/2021 03:42:18 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 GUEST HOMEFACILITY NUMBER:
507005360
ADMINISTRATOR:ESTHER TOLIAOFACILITY TYPE:
740
ADDRESS:664 PARADISE ROADTELEPHONE:
(209) 622-0295
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:12CENSUS: DATE:
12/17/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Sharon BasalduaTIME COMPLETED:
04:05 PM
NARRATIVE
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On 12/17/21 at 1:06pm, LPA Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with facility manager Sharon Basaldua and explained the purpose of the visit. Administrator Esther Toliao was not present but gave permission for Sharon Basaldua via phone to accommodate LPA and sign in her absence.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 12 bed Residential Care Facility for the Elderly with a current census of 12. Facility has a formal living/tv room area and 7 bedrooms for client use. A separate kitchen is down a hallway corridor. LPA also conducted the infection control domain tool.
The facility has a COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 115.5*F in the bathroom and room temperature reads 71*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 9/3/21. Facility has an emergency food and water kit. LPA observed bug killer fluid under sink of bathroom and accessible to residents in care. LPA also reviewed 3 staff files. Administrator certificate expires 8/28/2023
Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to Sharon Basaldua
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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 3
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 GUEST HOME
FACILITY NUMBER: 507005360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation bug killer fluid remaining in bottle was accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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Licensee will develop and submit a plan in place outlining the procedures for securing dangerous and toxic items from residents in care. Plan to be submitted to LPA by POC due date.

Licensee will conduct staff training on regulation 87309(a) and submit proof of training to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 GUEST HOME
FACILITY NUMBER: 507005360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not maintain staff training for S2, and S3. LPA observed S2's and S3's most recent documented training to contain less than 8 hours of annual dementia training and missing training for postural supports, restricted health conditions, and hospice care . This poses a potential health, safety, and personal rights risk to residents in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee will complete annual training for S2 and S3 per Health and Safety Code 1569.625(b)(2) and submit proof of completed training to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3