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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700908
Report Date: 02/09/2021
Date Signed: 02/09/2021 05:03:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ST. TIMOTHY'S HOMEFACILITY NUMBER:
392700908
ADMINISTRATOR:ALMENDRALA, MARIAFACILITY TYPE:
740
ADDRESS:9230 LARIAT LANETELEPHONE:
(650) 267-3248
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 0DATE:
02/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Richie and Maria AlmenralaTIME COMPLETED:
05:00 PM
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Introduction: Licensing Program Analyst (LPA) Eric Stone met with licensee Richie and Maria Almendrala, to conduct a unannounced TA visit via facetime on 2/9/2021 at 330 pm. For a 6 bed RCFE facility there are currently 0 residents and food, hygiene and cleaning supplies.

Visitor policy and visitor logs observed Staff and visitors enter the facility through ringing the locked front door, signs up in all restrooms and kitchens, all files and medical records in locked cabinet and clearly labeled

Physical plant was clean and in good repair. Kitchen was stocked with canned and dried goods, frozen meat and vegetables available. Perishables not yet purchased due to facility not yet being approved. Soap, sanitizer, paper towels, and hand washing signs were available at kitchen hand washing sink. Fridge registered at 40, freezer at -10 and sink had hot water at 105 with dish washer running.

Restrooms were stocked with soap, sanitizer, paper towels and signs. Showers with large with hand rails, running water in all toilet, showers and sinks.Employees have room with bed to break with in staff room. Staff is responsible to keep room clean. All residents live in shared 2 person bedrooms. Residents will have access to tv and activities.

Outside area If weather permits residents can go outside with table and chairs avlible. Gates are closed and fence in good shape. There are ramps leading into facility and bedrooms. Glass windows and doors to back yard. Communal Dining large dining room with 6 chairs on table, other options included eating in rooms and main living space.

Smoke detectors were tested in each room and worked, linin closet was large and partial stocked. Fire extinguisher last checked 10/13/2020.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Eric StoneTELEPHONE: 916-594-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021
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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