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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700908
Report Date: 03/19/2026
Date Signed: 03/19/2026 03:01:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20251003154007
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: 6DATE:
03/19/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Avia SinghTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Untiimely medical care resulted in sepsis
INVESTIGATION FINDINGS:
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On 3-19-2026 at 1:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with staff 2 (S2) and explained the purpose of the visit. LPA contacted Administrator Maria Almendrala and explained the purpose of the visit. Administrator gave permission for S2 to sign in her absense. During the course of this investigation, LPA reviewed various facility file documentation including physician’s report, medication log sheets, and care notes regarding resident1 (R1). Additionally, LPA reviewed hospital visit records pertaining to R1, and conducted interview with staff1 (S1).
Allegation: Untimely medical care resulted in sepsis. Based on documentation reviewed, it was revealed that on 10-14-2024, a facility care note reads: “Resident not feeling well, Administrator ask if she wants to see Doctor, she refused.” Additional care notes beyond this date did not indicate a follow up until 12-27-2024 which a care note states: “Resident sent to ER, barely response, weak and refused to eat breakfast…” Hospital notes reviewed revealed that a stage 3 coccyx wound was discovered on R1 upon admission to hospital on 12-27-2024. Additional diagnosis of severe sepsis was also noted in hospital notes. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20251003154007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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. TIMOTHY'S HOME
FACILITY NUMBER: 392700908
VISIT DATE: 03/19/2026
NARRATIVE
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On or about 1-4-2025, R1 was sent back to and accepted by facility for re-admission. Additional documentation review did not reveal facility follow up or other sufficient outside intervention for the stage 3 wound. On 1-28-2025, hospital notes revealed that R1 was received at hospital on this date with diagnosis of “severe sepsis most likely secondary to sacral decubiti.” According to pms.ncbi.nlm.nih.gov, a “sacral decubiti (pressure ulcers) are localized damage to the skin and underlying soft tissue over the tailbone, cause by prolonged pressure, friction, or shear…” Facility care notes state R1 was later discharged back to facility on 1-31-2025 with plans for hospice care. R1 passed away on 3-27-2025. Based on evidence reviewed, there is a preponderance of evidence to conclude that resident experienced a worsening condition of a wound within facility leading to a stage 3 wound and related diagnosis of sepsis. As a result, the above allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Health and Safety Codes. Failure to correct the deficiency may result in additional civil penalties. An immediate civil penalty in the amount of five-hundred dollars ($500) was issued in addition to citation due to a violation resulting in a severe injury. At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was conducted with S2, and a copy of this report was provided. Administrator was made aware of findings via phone call as she was off site. Appeal rights provided. LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20251003154007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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. TIMOTHY'S HOME
FACILITY NUMBER: 392700908
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2026
Section Cited
HSC
1569.39(b)
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1569.39(b). 1569.39 Assistance with accessing home health or hospice services; receipt of medical services. (b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice…This requirement was not met as evidenced by:
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Licensee to develop and submit a plan outlining appropriate steps taken to ensure timely medical attention for residents. Plan to include but not be limited to: How licensee will comply with regulation 1569.39(b)
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Based on evidence reviewed, licensee did not ensure appropriate and timely medical intervention for R1’s wounds leading to a worsening condition including severe sepsis. This posed an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
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