507005360-4-26-2022-27-AS-CYAG-CDUN8G-20220426101418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005360
Report Date: 04/22/2022
Date Signed: 04/26/2022 10:14:25 AM

Document Has Been Signed on 04/26/2022 10:14 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 GUEST HOME		FACILITY NUMBER:	507005360
ADMINISTRATOR:	ESTHER TOLIAO		FACILITY TYPE:	740
ADDRESS:	664 PARADISE ROAD		TELEPHONE:	(209) 622-0295
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	12	CENSUS: 12	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Esther Toliao		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility on 04/22/2022 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility caregiver, Sharon Basaldua who was requested by this LPA to go ahead and contact the facility designated Administrator, Esther Toliao, to inform her that CCL was present at this time. Brief interview conducted with the facility staff person. Current census was 12 residents. It was learned that this facility does not have any residents under the care of hospice at this time. It was learned that there were residents receiving care through home health at this time. Tour of this facility was conducted. The facility designated Administrator, Esther Toliao, arrived to this facility later on while this LPA was already conducting this visit. A review of the facility resident bedrooms was conducted. Resident bedroom furniture and furnishings were observed to be able to meet the needs of the residents at this time. A review of the facility restrooms was conducted. Grab bars were observed to be present and in functional order at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Kitchen area was toured. Lunch time meal was being served while this LPA was conducting this annual review. Food supply, located in facility office area, was reviewed for adequate 2-day perishable and 7-day nonperishable required quantities at all times. Dining area, living area, and all other areas designated for resident use were toured. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 09/03/2021 by Gateway Fire Extinguisher Company and in compliance at this time. Medication cart, located in dining area, was observed to be locked and made inaccessible to the residents at this time. A review of the policies, procedures, and maintenance of the medications was discussed with the facility staff person Sharon Basaldua.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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 4

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
	VISIT DATE: 04/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Laundry room, located adjacent to the kitchen area, was observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, chemicals, and laundry supplies were observed to be locked and made inaccessible to the residents at this time.
Linen closed was reviewed for adequate sheets, blankets, and towels in order to supply the needs of the residents in care.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms will need to be updated and submitted in CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was reviewed and given to the facility designated Administrator Esther Toliao.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/26/2022 10:14 AM - 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
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: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above since the flooring in (1) out of (3) restrooms had cracked tiles which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that a third party contractor will be secured with a plan to safely remove and replace the bathroom floor. A statement of correction, along with a copy of the contract for the floor replacement, will be completed and submitted into CCL by the due date of 04/29/2022.

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in a review of the facility bedroom windows revealed that some window screens were missing while others were in need of repair with holes and tears which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that repairs will be completed on the window screens to make sure that they do not have any tears or rips in them. Also the windows that were missing a window screen will be fitted with one as well. A statement of correction will be completed, along with a copy of the receipt for window screen repair/replacement, and submitted into CCL by the due date of 04/29/2022.

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	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/26/2022 10:14 AM - 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
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: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of the exterior grounds of this facility, the licensee did not comply with the section cited above since roofing material was used as a cover for the exterior walkways in the backyard area, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that the roofing material will be removed from all exterior walkways. A statement of correction, along with pictures of the cleared walkways, will be completed and submitted into CCL by the due date of 04/29/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4