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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700261
Report Date: 07/24/2023
Date Signed: 07/25/2023 08:24:13 AM


Document Has Been Signed on 07/25/2023 08:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ST. STEPHEN'S HOMEFACILITY NUMBER:
502700261
ADMINISTRATOR:ALMENDRALA, MARIAFACILITY TYPE:
740
ADDRESS:1309 OAKWOOD DRIVETELEPHONE:
(209) 488-4901
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 5DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Maria Almendrala TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA Lund met with staff and later with Administrator Maria Almendrala and explained the reason for the visit.
Census: 5

LPA Lund and Administrator Maria Almendrala toured/inspected the inside and outside of the facility. LPA Lund observed required posters. The facility was found to be clean, safe and sanitary, and in good repair. The facility temperature was comfortable. The hot water temperature measure at 111 degrees F. There are no bodies of water present at the facility. Toxins and sharp tools are stored inaccessible to residents. LPA observed 2- day perishable and 7 – day non-perishable food supply and menu. Fire extinguishers (July 2023), smoke detectors, and carbon monoxide detectors are in compliance. First Aid kit is complete. Disaster drill conducted within the last six months.

LPA reviewed 3 resident files and 2 staff files (reviewed staff has criminal record clearance). LPA Lund observed centrally stored medications are locked. LPA Lund observed that resident R1 needs and services plan was dated 6/1/2021.

Deficiencies were observed. Exit interview conducted Administrator Maria Almendrala report and Appeal rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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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Document Has Been Signed on 07/25/2023 08:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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. STEPHEN'S HOME
FACILITY NUMBER: 502700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87763(c)


This requirement is not met as evidenced by:LPA Lund observed that resident R1 needs and services plan was dated 6/1/2021.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Licensee with provide a needs and services plan for R1 to LPA Lund
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2