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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500310664
Report Date: 05/16/2024
Date Signed: 05/16/2024 10:52:59 AM

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
03/26/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240326121327
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:
05/16/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sister Basima Margaret Homa, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that the facility is free of hazards
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/16/24, LPA Renee Campbell arrived to the facility regarding a complaint filed on 03/26/2024. LPA Campbell met with Administrator, Sister Basima Margaret Homa and explained the purpose of the visit.

It was alleged that staff did not ensure that the facility is free of hazards. LPA Campbell took images of R1’s room with several extension cords on the floor obstructing pathways after a power outlet outage on approximately 03/25/24. S2 stated that extension cords were split and combined with other cords when they no longer worked and were then wrapped with electrical tape. LPA Campbell also recorded images of split cords wrapped with tape and then stored in the facility garage.

Based on the information provided through interviews and observation, the allegation that the facility did not ensure the facility is free of hazards is SUBSTANTIATED. The following deficiency was cited per Title 22 Division 8 Section 8 of the California Code of Regulations. An exit interview was conducted with Sr. Basima Margaret Homa and a copy of this report was left with the administrator.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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 2
Control Number 27-AS-20240326121327
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. THOMAS RETIREMENT CENTER
FACILITY NUMBER: 500310664
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation. (a) The facility shall be clean safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The facility will replace all cords that are not working or have been split and taped to other cords by 05/24/2024. Images of the new extension cords and surge protectors stored in the garage will be sent to LPA Renee Campbell at renee.campbell@dss.ca.gov
8
9
10
11
12
13
14
Based on observation and interviews, the licensee did not ensure R1’s room was safe and in good repair at all times, which poses a possible health, safety or personal rights risk to persons 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2