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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920012
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:12:23 PM


Document Has Been Signed on 08/28/2024 02:12 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SAINT THOMAS CARE HOMEFACILITY NUMBER:
345920012
ADMINISTRATOR:MAGUREAN, EVELINAFACILITY TYPE:
740
ADDRESS:4905 SAINT THOMAS DRIVETELEPHONE:
(916) 880-0551
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Evelina Magurean, AdministratorTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility to conduct a health and safety check and follow-up regarding technical assistance that was provided to the facility during an inspection conducted on 5/8/2024.

During today's inspection, LPAs toured the facility, reviewed documentation for centrally stored medications, and reviewed three (3) resident records and two (2) staff records. LPAs observed that one (1) caregiver did not have sufficient initial training per health and safety code. LPAs observed facility did not have logs documented for quarterly drills. LPAs also observed that facility was missing start dates for when medications were started for residents.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6. Deficiencies are listed on 809-D pages.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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Document Has Been Signed on 08/28/2024 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SAINT THOMAS CARE HOME
FACILITY NUMBER: 345920012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87465 and submit statement of understanding to LPA by POC due date of 8/29/2024.
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Based on LPAs' observations and records reviewed, the facility did not ensure that documentation for medication administered was complete, resulting in information missing pertaining to medication administration, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
09/12/2024
Section Cited
HSC1569.625(b)(1)

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§1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 1569.625 and submit statement of understanding to LPA by POC due date of 9/12/2024.
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Based on LPAs' observations and records reviewed, facility did not ensure that initial training was sufficient for one (1) caregiver per Health and Safety Code, which poses a potential health, safety or personal rights risk to persons in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/28/2024 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SAINT THOMAS CARE HOME
FACILITY NUMBER: 345920012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
HSC
1569.695

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§1569.695 Emergency Plans (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 notrequired 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:
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Facility will complete a statement of understanding regarding regulation 1569.695 and submit statement of understanding to LPA by POC due date of 9/12/2024.
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Based on LPAs' observations and records reviewed, facility did not ensure to document quarterly drills completed, which poses a potential health, safety or personal rights risk to persons in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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