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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507005360
Report Date: 10/12/2022
Date Signed: 10/21/2022 01:19:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220606152221
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:
10/12/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sharon BasalduaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 10/12/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Sharon Basaldua, who was requested by this LPA to go ahead and notify the Licensee/facility designated Administrator of LPA's presence at this time.
Brief interview conducted with facility caregiver Basaldua. Esther Toliao, facility designated Administrator, arrived shortly thereafter to this facility.
Current census was 11 residents.
Based on interviews conducted during the course of this investigation it was learned that this facility had a contract with a third pary vendor, Orkin Pest Control, since 2016 for monthly service. These services included exterior spraying for minor insects and bugs and interior treatments as needed. This contract with Orkin Pest Control was set to end on 10/26/2022. A new contract with another third party vendor, NewTech Pest Control, was slated to begin on 11/01/2022
With additional interviews conducted during the course of this investigation, it was learned that there were (2) residents, R1 and R2, who had issues with bed bugs with their personal belongings and furnishings.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220606152221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/12/2022
NARRATIVE
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These issues with bed bugs also affected another resident, R3, who was a roommate at this time.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator, Esther Toliao, 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: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220606152221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2022
Section Cited
CCR
80087(a)(1)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

(1) The licensee shall take measures to keep the facility free of flies and other insects.
This facility was found to be deficient as evidenced by the presence of bed bugs in
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The facility designated Administrator stated that treatment for the removal and eradication of bed bugs will be conducted throughout this facility once the new third party vendor contract goes into effect on 11/01/2022. A statement of correction, along with copies of services rendered, will be completed and submitted into CCL by the due date.
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(2) resident rooms. This posed a potential threat to the Health, Safety, and Personal Rights of residents in care.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3