<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700908
Report Date: 01/31/2023
Date Signed: 01/31/2023 05:22:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/31/2023 05:22 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, 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: 6DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Cecilia AmayaTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1-31-23 at 3:28pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the lead caregiver Cecilia Amaya and explained the purpose of the visit. Administrator Maria Almendrala was notified and gave permission for Cecilia to accommodate LPA and sign in her absence.

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 residential care facility for the elderly with a current census of 6. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place.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 backyard. 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. 6 of 6 resident files reviewed. Resident1 (R1) and R2 file did not contain a pre-admission appraisal per regulatory requirements. 2 staff files reviewed. Both files were missing updated first aid/CPR certification.

Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 74*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. Fire extinguisher was checked 1/19/2023. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held with Cecilia Amaya and a copy of this report was given to Cecilia
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/31/2023 05:22 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ST. TIMOTHY'S HOME
FACILITY NUMBER: 392700908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited

1
2
3
4
5
6
7
Personnel Requirements. (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training... (1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a plan to LPA ensuring first aid certifications are current. Plan to be submitted to LPA by POC due date.

Licensee will read regulation 87411(c)(1) and submit a signed declaration of understanding to LPA by POC due date.
8
9
10
11
12
13
14
Based on record review, first aid certification was not present in 2 of 2 staff files reviewed to indicate completed training. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
02/10/2023
Section Cited

1
2
3
4
5
6
7
Reappriasals. (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...This requirement is not as evidenced by:
1
2
3
4
5
6
7
Licensee will read regulation 87463 and submit a signed declaration of understanding to LPA by POC due date.

Licensee will complete appraisals and submit a plan ensuring completeness of resident records per regulatory requirements.
8
9
10
11
12
13
14
Based on record review, 2 of 6 resident files contained pre-admission appraisals not complete. This poses a potential health and safety risk for residents in care.
8
9
10
11
12
13
14
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2