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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005360
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:26:51 PM


Document Has Been Signed on 05/09/2024 03:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
05/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Sharon Basaldua, CaregiverTIME COMPLETED:
03:30 PM
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On 05/09/24, LPA Campbell arrived to the facility to review and provide technical assistance regarding their Medication Administrator Record (MAR). LPA Campbell explained the purpose of the visit and asked to see their MAR. During prior visits, LPA Campbell observed that the facility had not tracked resident usage for prescribed medication.

LPA Campbell had provided MAR templates to the facility. Instead of using them, the Facility Manager, John Villareal used them as a guide to create his own forms to increase the font for his employees and to make them easier to use. LPA Campbell observed that he further altered the forms from the Community Care Licensing template by highlighting the times that residents were scheduled to receive medication. LPA Campbell suggested that a Key be used in the MAR to identity unusual incidents such as emergency hospital and family visits or when residents refused to take their medication. LPA Campbell spoke with staff and identified the benefits of using the MAR to verify that staff were following procedure in cases of resident disputes around if a medication was provided. LPA Campbell and the staff at the facility will use the new MAR and assess the results during future LPA visits.

NOTE: During visit, LPA Campbell found that John Villareal had renewed his Administrator Certificate. He will provide his Administrator number and expiration number at a later time. No deficiencies have been cited during this visit.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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