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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200564
Report Date: 08/22/2022
Date Signed: 08/22/2022 06:53:02 PM

Document Has Been Signed on 08/22/2022 06:53 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FRANCIS HOUSEFACILITY NUMBER:
079200564
ADMINISTRATOR:BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:2449 GILL PORT LANETELEPHONE:
(925) 939-7700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Alberto BernardinoTIME COMPLETED:
07:15 PM
NARRATIVE
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On 8/18/22 at 3:30 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit with staff members who called Licensee Alberto Bernardino who arrived shortly thereafter and toured the facility inside and outside with LPA.

Facility cited for staff with no face mask who answered the door and for staff not associated with facility.

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan was posted. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 78.8 and the hot water was 120 degrees Fahrenheit, both of which were in the safe range. Toxic chemicals, over-the-counter medications, and sharp objects were inaccessible to the residents. Carbon monoxide and smoke detectors were functional. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Facility cited for fire extinguisher that had not been serviced since May 2020 and for not conducting Quarterly Emergency and Fire Drills.

Facility cited with 1 Type A and 3 Type B deficiencies. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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 4
Document Has Been Signed on 08/22/2022 06:53 PM - It Cannot Be Edited


Created By: James Sampair On 08/22/2022 at 05:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FRANCIS HOUSE
FACILITY NUMBER: 079200564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 CRIMINAL RECORD CLEARANCE (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 staff members, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee removed non-associated staff member from facility and replaced them with fully associated staff.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/22/2022 06:53 PM - It Cannot Be Edited


Created By: James Sampair On 08/22/2022 at 06:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FRANCIS HOUSE
FACILITY NUMBER: 079200564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in with fire extinguisher that had not been replaced or recharged since May 2020, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licencee shall replace fire extinguisher and send LPA proof on or before due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/22/2022 06:53 PM - It Cannot Be Edited


Created By: James Sampair On 08/22/2022 at 06:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FRANCIS HOUSE
FACILITY NUMBER: 079200564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when a staff member who greeted LPA upon entry did not have a face covering, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Administrator shall review with all staff their infection control plan and the PIN 22-15-ASC and confirm this review has been conducted with the LPA by the due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because the only emergency drill conducted in 2022 was the one on 3/10/2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Administrator shall conduct an emergency drill with residents and staff. Plus, Administrator will review with staff their Emergency and Disaster Plan. Administrator will attest to the completion of these tasks with the LPA by the due date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
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