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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700261
Report Date: 07/09/2026
Date Signed: 07/09/2026 03:14:12 PM

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
02/18/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260218134153
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: DATE:
07/09/2026
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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resident was not assisted with medications as ordered
INVESTIGATION FINDINGS:
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Licensing program Analyst, LPA, Noel Wolf Petersen arrived to the facility at 10:30am to conduct a complaint investigation into alleged violation above. Met with the staff and then the administrator Maria Almendrala by phone to explain the purpose of the visit

As to the allegation that a resident was not assisted with medications as ordered, R1 made a statement that their Mar records were falsified and their morphine medication was not distributed as perscribed. a statement from the administator was made regarding R1 that the morphine order was made for PRN pain management, and that the staff did not find signs and symptoms for pain, and therefore there were times when the staff did not distribute the medication. Several elements in the record review of documents were presented:

Continued on c. page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
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 6
Control Number 27-AS-20260218134153
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: 07/09/2026
NARRATIVE
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~In R1's MAR there was an order for perscribed morphine in tablet form which is filled out as distributed appropriately according to the order,
~In the resident R1's discharge notes from 5/7/26 Almond Vista, the prescription reads as 1 per 12 hours, no modulation asterisks for a hold, no language indicates an "as needed" basis.
~In record review, it was learned that S1 had filled out at least one MAR(R4) log with entry's where they described themselves as being out of the facility, in interview S1 stated they had falsely entered into the MAR that they had distributed medication when it was not them who distributed the medication, and was not here in the facility to witness if the medication was distributed.
~602 for the resident indicates the ability to administer their own medication, not being coginatively impaired, and the ability to commuicate needs, and past medical history indicates multiple sources of chronic pain (fractures)
~Needs and services plan, indicates R1 needed all ADL's assistance due to pain
~The controlled substances log does not have a morphine entry
~ A record review of the MARs of 5 clients can't support the missing medications for any resident, but also is being filled out by a staff after the fact, difficult to tell whats true

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.)

Citation was issued on the following D page, a copy of the report was read and given to the staff designated by the administrator. appeal rights provided, an exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
02/18/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260218134153

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: DATE:
07/09/2026
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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facility did not follow admissions agreement and added additional fees
Staff did not reorder residents medication timly
staff do not speak to residents in a respectful manner
facility limited access to the community
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to conduct a complaint investigation into the above allegations, LPA met with administrator Maria Almendrala by phone to explain the purpose of the visit.

As to the allegation that the facility did not folow the admission agreement and added additional fees: The LPA reviewed the admission agreement and invoices supplied to the resident(r1). The admission agreement does not outline a specific charge rate for a specific broken item. R1 reported that they were charged for a TV to replace a broken tv in 40$ instalments and this was a not a charge they agreed to, but were informed of verbally by the administror. R1 further made the claim that a processing fees' fee was levied against them. LPA's review of the invoices May 2024 to December 2024 supplied by the administator indicates a basic rate charge and a seperate cable charge and occassionally a co-pay for Morphine specificly or Medication in general. It's unclear if the TV was rolled into the basic rate or not. LPA gave guidance that the methods of attempts to collect damages from the residents should be outlined clearly in the admission agreement, and itemized on an invoice. 1 of 6 residents agreed with the statement that the facility had not followed the admission agreement and added addtional fees.
Continued on c page
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20260218134153
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: 07/09/2026
NARRATIVE
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As to the allegation that the staff do not speak to residents in a respectful manner, it was reported by r1 that staff were rude to them and other clients, when the staff discontinued thier percocet medication the client was told "Nobody needs that" by S1, R2 was yelled at to change clothes and take a shower by S3, and R3 was yelled at when they would smoke in the bathroom. S3 and R3 were unavailible for interview by the LPA. R2 did not corroberate being yelled at. S1 reported R4 and R3 being upset occassionally and using some racist terms to the staff. R4 had heard R3 and a staff he did not identify going back and fourth in an argument where both sides were shouting. 2 of 6 residents agreed to the statement that staff do not speak to residents in a respectful manner.

as to the allegation that the facility limited access to the community, it was reported by r1 that they and r2 were not allowed to go more than down the slope of the entry ramp by S3. It was further reported by r1 that they were prohibited by the staff(s3) from going to the pharmacy or her doctors office, to the degree of turning away the dial a ride service R1 had arraanged for transprot. It was further reported by r1 that they were prohibited from attending church services. Record review of the 602 for R1 indicated they were able to leave the facility unassisted "with family". No documentation was made, so it is unclear that distinction was ever explained by the facility to the resident, or that an effort was made to address the expressed pharmacological or religious needs of the resident. S1 and the admin both reported that the resident never was denied access to the community inappropriately. Admin reported that the dial a ride service was being charged to the facility rather than the resident, and there was a misscommunication between the facility and the resident about why they were not allowed to make use of the dial a ride service in that particular instance. 2 of 6 of the residents agreed with the statement that they had experinced an issue with accessing the community.

As to the allegation that staff did not reorder residents medications timely: R1 reported that S1 was instructed by the administrator to hold off on telling them when a medication was about to run out until after normal buisness hours of thier perscribing doctor. R1 further reported that there were resulting periods where the facility was not able to deliver all medication as perscribed, and due to the delay in reciving a particular pain management medication from the staff, R1 took it upon themselves to either arrange transport to the emergency department to recive pain managment medication or arrange for thier perscribing doctor to make the medication availible at the pharmacy for pick up. R1 further reported that the administrator did not act to pick up the medication from pharmacy when it was availible and limited access to the community ofthe client to leave the facility to pick up the medication.

Continued on C2
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20260218134153
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: 07/09/2026
NARRATIVE
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The administrator, in interview denied refusing to pick up a medication that was availible. In staff interviews, S1 provided the statement that residents (r1, r4)medications were occasionally delivered late by the pharmacy, but not as a result of the facility failing to order the medication timely or being instructed to delay ordering a medication.

In record review, there is no log of care notes available describing phone calls staff made on behalf of the residents to the pharmacy. The MAR for 5 clients doesn't indicate gaps for medication distribution, but additional details bring the utility and truthfulness of the MAR into question on the substantiated allegation associated with this complaint. 1 family member FM1, indicated that they were present for med passes where clients were given half doses of medications by staff and were told that the facility did not have the medication available. 2 of 6 residents agreed with the statement the facility was not reordering medications on time.

4 residents were interviewed as part of this visit, 2 self reported memory issues.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

A copy of the report was read and given to the administrator. exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20260218134153
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: 07/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2026
Section Cited
CCR
87465(a)(1,2)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
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POC Suggestion is do a staff training on how to document MAR records, PRNs, medication Refusals, and controlled substances, Medication distruction record. Training should be with a vendor/hospice/homehealth nurse and not the administrator. 8/10/26
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This requirement was not followed as evidenced by:

In record review, The morphine is a controlled substance and is not being recorded properly on a controlled substances log. In interview, perscribed order(1 per 12 hours) conflicts with the administrators statement (PRN). its distribution as a MAR record is questionable, per interview with S1.

This requirement not being followed poses a risk to the health, safety, and personal rights of clients in care.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6