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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500310664
Report Date: 05/10/2024
Date Signed: 05/10/2024 04:10:33 PM


Document Has Been Signed on 05/10/2024 04:10 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:SR.BASIMA MARGARET HOMAFACILITY TYPE:
740
ADDRESS:2937 NORTH BERKELEY AVENUETELEPHONE:
(209) 634-7252
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:49CENSUS: 38DATE:
05/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Sr. Basima Margaret HomaTIME COMPLETED:
04:15 PM
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On 05/10/24, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management visit regarding a medication error. LPA Campbell met with Administrator Sr. Basima Margaret Homa and explained the purpose of the visit.

Per the incident report provided to licensing, Resident 1 (R1) received the incorrect dosage for 4 days. R1's doctor was immediately notified. The Administrator reported that the Med Tech (M1) involved in the medication error was involved in other ongoing issues regarding their performance. M1 then resigned when required to write a report recounting the incident. The administrator also stated that M1 had already given two weeks notice beforehand. Per the doctor's orders, a "plan of correction" was needed to avoid the mistake being repeated. The administrator now requires that 2 staff will need to check and verify accuracy before making changes to the doctor's order.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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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