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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200564
Report Date: 03/30/2023
Date Signed: 03/30/2023 06:01:47 PM

Document Has Been Signed on 03/30/2023 06:01 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:EDLOR SAPALARANFACILITY TYPE:
740
ADDRESS:2449 GILL PORT LANETELEPHONE:
(925) 939-7700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alberto BernardinoTIME COMPLETED:
06:00 PM
NARRATIVE
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On 03/30/2023 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted a required annual inspection. Upon entry, LPA explained the purpose of the visit to staff member S1. At 9:20 AM, Co-Administrator Alberto Bernardino (Administrator Certificate #6005406740 expiration 10/26/2023).

LPA inspected the facility inside and outside. The facility's fire clearance was approved for 6 non-ambulatory residents, one of which may be bedridden in Room 101,102, or 105. There were no bodies of water present at the facility. Inside and outside pathways were free of obstruction and fire hazards. There were six (6) residents at the facility during inspection. All residents were observed to be well groomed and clean.

The facility has a written Emergency/Disaster plan updated during visit 03/30/2023, which was posted on a bulletin board near the front entrance. Centrally stored medications were locked in a closet next to the main front entrance. Sharp objects were locked in the kitchen drawer next to the sink. Toxic chemicals were locked in a cabinet inside the garage. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 74 degrees Fahrenheit.

Cited for hot water temperature of 123 degrees Fahrenheit in the kitchen, which was reduced to 110 degrees at 4:40 PM. Resident's bathrooms have grab bars inside the shower and next to the shower. The shower has a non-skid mat.The facility has trained staff in Dementia Care, Medication, and Basic Training. Fire extinguishers were fully charged and last inspected on 08/22/2022.

Staff records were reviewed on 03/30/2023 at 04:05 PM. The facility staff all had criminal record clearances to work and are associated to the facility. Resident records all contain Admission Agreements, medical assessments, needs and service plan/appraisals. The facility serves residents with Dementia. The facility has potentially dangerous objects locked and inaccessible to residents in care. The facility has auditory signals on each sliding door in the resident's room. Staff at the facility has the required Dementia training.

Continued on next page LIC 809-C . . .
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FRANCIS HOUSE
FACILITY NUMBER: 079200564
VISIT DATE: 03/30/2023
NARRATIVE
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. . . Continued from page LIC 809

Facility cited for 1 A, 2 B, and 2 Technical Violations from the California Code of Regulations of Title 22 (see LIC 809-D). Failure to correct these deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted and appeal rights provided to Administrator via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/30/2023 06:01 PM - It Cannot Be Edited


Created By: James Sampair On 03/30/2023 at 04:50 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: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 the kitchen where the temperature was measured at 123 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Cleared during visit. Temperature reduced to 110 degrees F when measured at 4:40 PM.
Section Cited
Deficient Practice Statement
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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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/30/2023 06:01 PM - It Cannot Be Edited


Created By: James Sampair On 03/30/2023 at 04:56 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: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
87305 Alterations to Existing Buildings or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.

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 the garage where structure had been built that was being used for staff break area, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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Licensee will send pictures on or before due date of garage interior after room has been removed.
Type B
Section Cited
CCR
87705(h)
87705 Care of Persons with Dementia (h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

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 the side gate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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Licensee will send pictures on or before due date of new self-closing spring, latch, and closing side gate after they have been installed.
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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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