507005360-5-2-2023-27-AS-CYAG-CRFUR5-20230502154810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005360
Report Date: 04/28/2023
Date Signed: 05/02/2023 03:48:14 PM

Document Has Been Signed on 05/02/2023 03:48 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
SACRAMENTO AC/SC, 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: 11	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Esther Toliao		TIME COMPLETED:	01:00 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 04/28/2023 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility designated Administrator, Esther Toliao, who was briefly interviewed at this time. Current census was 11 residents and the facility designated Administrator stated that a new admission was going to take place later on today. A new resident did arrive and was admitted into this facility while this LPA was conducting this visit. This facility is contracted through various counties to accept and retain residents diagnosed with mental health issues. Tour of the facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time. Tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Fire extinguishers, located throughout this facility, were reviewed to observed to have been annually inspected on 09/18/2022 by the local fire extinguisher company, Gateway Fire Extinguisher Company, and in compliance at this time. Laundry room, located adjacent to the kitchen area, was toured. Laundry detergents, cleaning supplies, and bleach were all observed to be locked and made inaccessible to the residents at this time. A review of the facility 2-day perishable and 7-day nonperishable food quantities was conducted. All of the food supplies were maintained and stored in an area that was adjacent to the facility office. This LPA observed additional food storage units was well. Medication cabinet, located in the office area, was reviewed. Policies and procedures were discussed with the facility designated Administrator in terms of handling, dispensing, and documentation of resident meds.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ST. FRANCIS GUEST HOME	FACILITY NUMBER: 507005360
	VISIT DATE: 04/28/2023

NARRATIVE

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First aid kit was observed to be present and contained all of the required components at this time and observed to be in compliance.
Linen closet was reviewed and observed to contain all of the necessary blankets, towels, and linens sufficient to meet the needs of the residents at this time.
A tour of the exterior grounds was conducted.
A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (5) facility residents files was conducted.
A review of (3) facility personnel files was conducted.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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