<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005360
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:47:28 PM


Document Has Been Signed on 04/11/2024 04:47 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: 10DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:TIME COMPLETED:
05:00 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
On 04/11/2024 at 2:00 pm, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection. LPA Campbell met with Sharon Basaldua, Caregiver and John Villareal, Manager. LPA Campbell explained the purpose of the visit and both assisted with the inspection.

This facility is a single story building licensed 12 clients of which 6 may be non-ambulatory clients. LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Campbell observed the facility to be free of odor, and in good repair. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Campbell toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. In the bathroom, grab bars and non-slip mats were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are connected to the fire department. The fire extinguisher is located in the living room and near the second bathroom and was last serviced on 09/14/2023. LPA Campbell observed the facility has a public telephone in the common room. The facility has an infection control plan and an emergency disaster plan. Facility thermostat was observed at 73 degrees Fahrenheit. LPA Campbell observed toxins located in the kitchen which is kept locked and inaccessible to clients. LPA Campbell observed sharp knives kept locked away in the locked kitchen and inaccessible to clients. LPA Campbell checked medication storage and found the medication cabinet was kept in the dining room and locked and inaccessible to clients.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 507005360
VISIT DATE: 04/11/2024
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
The first aid kit was checked and contained all of the required components. LPA Campbell requested client and staff files for review. LPA Campbell reviewed 2 out of 10 client files and 2 of 5 staff files.

During today’s visit, LPA Campbell provided a TA to the Manager to ensure all files meet Title 22 guidelines.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2