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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700908
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:59:27 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
01/05/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240105132112
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: 5DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Maria AlmendralaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not retrieve a prescribed medication for a resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3-19-24 at 2:27pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Administrator Maria Almendrala via phone and explained the purpose of the visit. Administrator gave permission for staff2 (S2) to sign paperwork in her absence.

During this investigation LPA conducted interviews with two staff members and resident1 (R1). LPA also reviewed facility file documentation including care notes and medication log sheets for R1.
Based on interviews, it was determined that R1 was to receive a prescribed antibiotic medication on 1-2-24 after a stay at the hospital. It was further determined through interviews that although facility staff verbalized attempts to retrieve the medication for R1, there was no evidence to prove such attempts were made by facility staff. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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-20240105132112
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: 03/19/2024
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
26
27
28
29
30
31
32
Record reviews revealed no attempts by facility staff to retrieve medication during the above time period, and it was determined that R1 did not receive medication as prescribed. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citation is issued under Title 22, Division 6, Chapter 8 and noted on LIC 9099D. An exit interview was conducted with S2 and a copy of this report was provided to S2. Appeal rights provided. Copy of LIC 811 provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240105132112
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465(a)(4). Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility… (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a plan outlining effective procedures for facility staff to ensure effective and timely retrieval of residents’ medications. Plan to be submitted to LPA by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, Licensee did not ensure the retrieval of a prescribed medication for R1. This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3