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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005360
Report Date: 05/05/2022
Date Signed: 05/13/2022 01:41:52 PM


Document Has Been Signed on 05/13/2022 01:41 PM - 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 HOMEFACILITY NUMBER:
507005360
ADMINISTRATOR:ESTHER TOLIAOFACILITY TYPE:
740
ADDRESS:664 PARADISE ROADTELEPHONE:
(209) 622-0295
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:12CENSUS: 11DATE:
05/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Esther ToliaoTIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced Plan of Correction visit conducted on 05/05/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua who were met by the facility caregiver, Sharon Basaldua, and requested to go ahead and contact the facility designated Administrator, Esther Toliao, to inform her that CCL was present at this time. The facility designated Administrator arrived shortly thereafter to this facility.
Current census was 11 residents.
The purpose of this visit was to review the deficiencies cited on a prior visit conducted on 04/22/2022 with a plan of correction.
LPAs toured the facility and reviewed the deficiencies to make sure that they had been corrected and brought into compliance at this time.

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.

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.
The plan of correction letter was completed and a copy left with the facility designated Administrator.

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.

There were no deficiencies observed or cited at this time. Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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