500310664-4-19-2024-27-AS-RCAL-D4GVFR-20240419162423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500310664
Report Date: 04/19/2024
Date Signed: 04/19/2024 04:24:35 PM

Document Has Been Signed on 04/19/2024 04:24 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 CENTER		FACILITY NUMBER:	500310664
ADMINISTRATOR:	SR.BASIMA MARGARET HOMA		FACILITY TYPE:	740
ADDRESS:	2937 NORTH BERKELEY AVENUE		TELEPHONE:	(209) 634-7252
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY:	49	CENSUS: 38	DATE:	04/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Sister Basima Margaret Homa, Administrator		TIME COMPLETED:	04:45 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 04/19/2024 at 8:39 AM, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection. LPA Campbell met with administrator Sister Basima Margaret Home. LPA Campbell explained the purpose of the visit. The administrator assisted with today’s visit. The current census is 38 residents and 37 facility staff which consist of 3 housekeepers, 4 Med-techs, 11 caregivers, 2 cooks and the administrator. The administrator's certification number is #6025873740 and the expiration is 4/29/2025. This facility is a single story building licensed to serve 49 non-ambulatory residents ages 60 and over and is approved for 10 hospice residents. LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Campbell observed the facility to be free of odor, clean and in good repair. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and lighting. All residents had their own bathrooms. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Residents had access to shower chairs. There are no bodies of water present. LPA Campbell toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. The Turlock Fire Department Inspection form was observed by LPA Campbell for the current and prior two years for the smoke and carbon monoxide alarm inspections. The fire department gave a “Pass” or “All Clear” for each inspection. cont. LIC809C

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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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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: 04/19/2024

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The facility has an infection control plan and an emergency disaster plan. The facility thermostat was observed at 73 degrees Fahrenheit. However, per observation of a sampling of rooms by LPA Campbell, all resident rooms have individual thermostats. A fire extinguisher was observed in the kitchen and was last serviced on 06/05/2023. LPA Campbell observed toxins or cleaning products located in a closet in the kitchen and another in a residential hallway closet. Both were locked and inaccessible to residents. LPA Campbell also observed cleaning products in the laundry room in use by staff. The laundry door is locked when staff are not doing laundry and present in the room. LPA Campbell observed knives in use by kitchen staff stored in a knife block. After hours, the kitchen is locked and inaccessible to residents. The freezer temperature was -5 degrees Fahrenheit, and the refrigerator temperature was observed to be 40 degrees Fahrenheit. LPA Campbell reviewed 4 out of 38 residents files and they were found to be complete.

Based on today's inspection conducted by LPA Campbell, no deficiencies are being cited. Exit interview held and copy of report left.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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