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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500310664
Report Date: 07/01/2026
Date Signed: 07/01/2026 05:24:26 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/01/2026 05:24 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ST. THOMAS RETIREMENT CENTERFACILITY NUMBER:
500310664
ADMINISTRATOR/
DIRECTOR:
SR.BASIMA MARGARET HOMAFACILITY TYPE:
740
ADDRESS:2937 NORTH BERKELEY AVENUETELEPHONE:
(209) 634-7252
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY: 49CENSUS: 39DATE:
07/01/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Sister MargaretTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility, to conduct a annual inspection of the facility. LPA met with Sister Margaret Homa and explained the purpose of the visit. The facility is a 49 bed facility there are some care conditions that are currently self managed in the facility, 1 catheter, 1 colostomy, 2 diabetics. 3 clients are currently on hospice.

LPA physically inspected the facility, including 6 bedrooms and bathrooms of the residents, exteriors, evacuation route gate, kitchen. Facility is clean, traffic areas are unobstructed and well lit.

Kitchen has adequate supply of food to accommodate 2 days perishable and 7 days non perishable. The LPA observed lunch, meat and veg, adequate in quality for consumption regulation and quantity for nutrition regulation. The residents during the service seemed happy with the food in a general sense. Kitchen has adequate lockable storage for sharps and toxics to be stored seperately from each other and food. Kitchen has daily menu posted on a community channel that broadcasts to the Resident's TV's, and takes input during the intake process for prefered foods and dietatry restrictions. Alternate meals provided for medical necessity or convenience are possible with advance notice to the kitchen. Senior Chef claims to have adequate equipment to serve the menu. Kitchen is clean, grease traps look good.

Bedrooms/bathrooms have hardware in good repair, and all required furniture and furnishings. Some clients have extensively personalized their room, others have not. Water temperature was measureed low and high at differenct sinks in the facility, LPA asked the senior maintenance staff to recalibrate the water heaters to deliver between 105-120*F to all the residents rooms on the water circuit.

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NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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. THOMAS RETIREMENT CENTER
FACILITY NUMBER: 500310664
VISIT DATE: 07/01/2026
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Common areas and exteriors are clean, have space for activities. Some public areas have video only camera surviellance, LPA asked for the facility to add to the admission agreement an amendment document that notifies the resident they would be potentially video recorded. One balcony fence is out of repair, Maintenance Director was made aware of the fence and immediately put in a work order. evacuation route is a open parking lot, its accessible from most exits from the facility with cement sloped walkways of at least 36 inches.

MARs/Medication inspection had doses missing in the MARs for 3 clients for routine medication passes. One client was missing 1 medication on 2 days in a row. Explanation given to the LPA verbally was that the doses were forgotten to be recorded, explanation did not make it to the daily log. LPA noted medication doses were not forgotten to be logged with other medications dispersed at the same time. One client was missing multiple (3+) medications on 5pm and 8pm dispersals for the 30th of June. Explanation given to the LPA verbally was that other concerns going on with the client at the time(client refusing medications, hospice complication), explanation for the refusal made it to the log, record was not updated to reflect the status of the other medications dispersed or not dispersed. One clients MARs for the 8am morning dispersal was missing 7/1/26. LPA was given the verbal explanation that the log for this morning has yet to be filled out, LPA was checking the logs at 1pm, after the noon dispersal. LPA gave guidance to use the daily notes sections of the log invesigate issues with the dispersal log.

Signal system in use was tested, response time was 27 seconds.

First aid kit has all requred items. fire extinguishers are dated May/2026.

Administrator records were reviewed, required postings (ombudsman, federal workers rights, patient rights, evacuation route on facility sketch), liability insurance, infection control plan, evacuation plan, Administrator certificate, and facility license. Files are present and up-to-date,

9 Client files were reviewed, preapprisial, admission agreements, recent 602/603, health screening, and incident reports. files are present and up to date.

5 Staff files were reviewed. health screenings, first aid/cpr, background checks, and starting employee paperwork. files are present and up to date. Contining training, every month hour different topics, is kept seperately from the staff files.

4 staff and 1 administrator was interviewed. 4 clients were interviewed.

No citations issued, a copy of the report was read and given to the administrator. exit interview completed
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC809 (FAS) - (06/04)
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