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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700908
Report Date: 07/02/2021
Date Signed: 07/02/2021 03:46:03 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: DATE:
07/02/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Maria AlmendralaTIME COMPLETED:
03:45 PM
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On 7/2/21 at 1:05pm, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a 90-day post licensing inspection visit. LPA was greeted by caregiver and LPA explained the purposes of the visit. Administrator Maria Almendrala arrived at 2:30pm and LPA explained the purpose of the visit.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed facility with a current census of 6. LPA was screened upon entry for temperature and asked to sign in. Facility has an entry security gate leading to entry door. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. Administrator certificate posted and expires 9/28/22.
The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F
Water temperature reads 106.8*F in the bathroom and room temperature reads 75*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit.
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Maria Almendrala
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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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