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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500310664
Report Date: 12/31/2020
Date Signed: 12/31/2020 10:30:00 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2020 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201022143503
FACILITY NAME:ST. THOMAS RETIREMENT CENTERFACILITY NUMBER:
500310664
ADMINISTRATOR:SR.BASIMA MARGARET HOMAFACILITY TYPE:
740
ADDRESS:2937 NORTH BERKELEY AVENUETELEPHONE:
(209) 634-7252
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:49CENSUS: 40DATE:
12/31/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maragret Basima, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility put padlocks on the gate where residents smoke
INVESTIGATION FINDINGS:
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On 12/31/2020, Licensing Program Analyst (LPA) T. White contacted the facility to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA White discussed the purpose of the call and the elements of the allegation with Administrator, Margaret Basima.

During the course of this investigation, the department reviewed photos, conducted tele-visit and interviews. On 10/28/2020, LPA toured the facility and observed a padlock located on the outside gate. Based on S1’s interview, the padlock on the gate is used for two dementia residents who like to wander out of the facility. S1 stated the padlock is not to permit residents from smoking, its for the safety of dementia residents. S1 stated the residents previously sat and smoked in that area, but the location has been moved. S1 stated we have created a new location for residents to smoke. Based on R1’s interview, the smoking area has moved to a new location.

Report continues on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
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 4
Control Number 27-AS-20201022143503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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. THOMAS RETIREMENT CENTER
FACILITY NUMBER: 500310664
VISIT DATE: 12/31/2020
NARRATIVE
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On 12/30/2020, S1 stated there are a total of 7 emergency exits. S1 stated 6 out of 7 emergency exits are accessible for residents. Based on facility sketch, LPA observed 7 of 7 emergency exits should be accessible to residents. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D.

Exit interview conducted with Administrator, Margaret Basima and copy of report and appeal rights provided via email.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20201022143503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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. THOMAS RETIREMENT CENTER
FACILITY NUMBER: 500310664
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2021
Section Cited
CCR
87202(a)
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87202(a): Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...

This requirement was not met as evidence by:
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Administrator agreed to remove the lock and provide a statement of understanding that exit doors should not be locked. Administrator agreed to provide appropriate plans to monitor residents with dementia at all times and submit copy to CCLD by 01/04/2020.
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Based on observation and interviews, facility did not comply with section 87202(a). LPA observed facility addded a padlock on the facilityemergency exit gate, which poses an immediate health and safety risks 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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2020 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201022143503

FACILITY NAME:ST. THOMAS RETIREMENT CENTERFACILITY NUMBER:
500310664
ADMINISTRATOR:SR.BASIMA MARGARET HOMAFACILITY TYPE:
740
ADDRESS:2937 NORTH BERKELEY AVENUETELEPHONE:
(209) 634-7252
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:49CENSUS: 40DATE:
12/31/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maragret Basima, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff threatened resident with eviction
INVESTIGATION FINDINGS:
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On 12/31/2020, Licensing Program Analyst (LPA) T. White contacted the facility to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA White discussed the purpose of the call and the elements of the allegation with Administrator, Margaret Basima.

During the course of this investigation, the department conducted interviews, and collected documentation. Based on interviews with Resident #1 (R1), R1 requested that the complaint be cancelled. R1 stated staff never threatened resident with eviction. Based on interviewed with Staff #1 (S1), staff never threatened resident with eviction. LPA observed there is no reasonable basis for this complaint.

Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies cited. Exit interview conducted with Administrator, Margaret Basima and copy of report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4