502700261-11-21-2023-27-AS-KHOS-CY4NCR-20231201092111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700261
Report Date: 11/21/2023
Date Signed: 11/21/2023 10:44:46 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
07/06/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230706143717

FACILITY NAME:	ST. STEPHEN'S HOME		FACILITY NUMBER:	502700261
ADMINISTRATOR:	ALMENDRALA, MARIA		FACILITY TYPE:	740
ADDRESS:	1309 OAKWOOD DRIVE		TELEPHONE:	(209) 488-4901
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	6	CENSUS: 6	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Maria Almendrala		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Facility failed to provide records to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with licensee/administrator Maria Almendrala and explained the purpose of the visit.

This investigation consisted of record review and interviews.

CCLD received a written statement from the reporting party of this complaint, alleging that multiple requests for documentation had been made by representatives of a resident’s (R1) responsible party (R1’s RP) via fax. The complainant provided two letters requesting R1’s complete resident records dating from 1/1/19 to present. The letters were dated 5/2/23 and 6/6/23.

[continued on 9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230706143717

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. STEPHEN'S HOME	FACILITY NUMBER: 502700261
	VISIT DATE: 11/21/2023

NARRATIVE

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The first of these two letters included R1’s advance health care directive, appointing R1’s RP as R1’s attorney-in-fact, along with a written authorization for this facility to release R1’s records to the complainant, which was signed by R1’s RP and dated 4/24/23. The second of these two letters reiterated the request for documents. Both letters were sent via fax.

LPA Moleski reviewed R1’s file at the facility and observed a letter, dated 4/27/23, sent to the facility by representatives of R1’s RP. The letter outlined a request for R1’s complete resident records dating from 1/1/19 to present. LPA Moleski reviewed R1’s LIC 601 and observed that R1’s RP was listed as R1’s responsible party.

During an interview, Almendrala confirmed that she had received both letters sent by representatives of R1's RP via fax. Almendrala provided copies of the letters to LPA Moleski. Almendrala said that, prior to receiving these faxed letters, she had provided R1’s RP with R1’s admission agreement, and no further documents. Almendrala said she took no further action after receiving the faxed letters.

LPA Moleski interviewed a representative of the complainant on 11/17/23. The representative said the complainant no longer needs the documents requested.

The department has determined the following as it relates to the allegation that the facility failed to provide records to a responsible party:

Based on record review and interview with Almendrala, records were not provided within two days as required. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87468.2(a)(19). An exit interview was held with Almendrala. Appeal rights and a copy of this report were left with Almendrala.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230706143717

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. STEPHEN'S HOME	FACILITY NUMBER: 502700261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/22/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	22 CCR Section 87468.2(a)(19) – Additional Personal Rights of Residents in Privately Operated Facilities: “To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.” This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review 22 CCR Sections 87506(c)(1) and 87468.2(a)(19) and write a signed statement acknowledging having done so and asserting that these sections will be complied with in the future. Licensee agrees to send LPA Moleski a copy of this signed statement by the POC due date. Failure to correct this deficiency by the POC due date will result in civil penalties. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on record review and interview, the licensee did not provide R1, represented by R1's RP, represented by the complainant, with R1's resident records within two days of receiving a written records request, which poses a potential health, safety, and/or personal rights risk.	8 9 10 11 12 13 14
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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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

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