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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700261
Report Date: 08/18/2026
Date Signed: 08/18/2026 04:56:21 PM

Document Has Been Signed on 08/18/2026 04:56 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. STEPHEN'S HOMEFACILITY NUMBER:
502700261
ADMINISTRATOR/
DIRECTOR:		ALMENDRALA, MARIAFACILITY TYPE:
740
ADDRESS:1309 OAKWOOD DRIVETELEPHONE:
(209) 488-4901
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 6DATE:
08/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maria AlmendralaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to conduct annual visit. The LPA met with the administrator Maria Almendrala to explain the purpose of the visit. St.Stevens home is a 6 bed facility licensed for 3 ambulatory and 3 non ambulatory with a maximum of 2 hospice clients. 1 client is currently on hospice, 1 client has dementia, 1 client has major neurocognative disorder.

Physical inspection was conducted, including but not limited to the bedrooms, bathrooms, kitchen, common areas, exterior and evacuation route gates. facility is clean, traffic areas are well lit.

~Kitchen has lockable storage for sharps, medications, toxics, LPA observed the lock off of the sharps drawer, it was not unattended. 1 clients access to sharps are suspect. there is adequate food for 2 days perishable, 7 days non perishable meals. LPA gave guidance that the bulk foods in containers (rice/cereals should have their labels of the orginal packaging stored with the items.)
~Bedrooms have mostly all required furniture and furnishings, including mattress encasements. LPA observed 4 bedrooms without chairs. LPA observed 2 beds equipped with half rails. LPA gave guidance the bedrails should be removed if the residents do not have an order from a doctor. LPA observed oxygen tank in Bedroom, the client doesn't require oxygen. LPa gave guideance to not use client bedrooms as storage.
~Bathrooms have hardware in good repair, the water temp measured at the basin is 121*F. Water heat was downadjusted while the LPA was in the facility, LPA gave guidance to set the heater between 110 and 115 to account for seasonal variation.
~Common/Exterior Areas, there is adequate space for activities. 5 residents were watching tv when the LPA arrived, 1 resident was listening to classical music
~evacuation Routes Gates, do not swing freely and latch closed. Three out of three gates drag into the concrete, LPA observed that the fence shared with the eastward neighbor is significantly out of repair and has missing boards, posts connected to nothing, and may ultimately be the cause of the gates dragging into the ground. LPA observed a deadbolt for the emergency gate, LPA gave guidance to remove the dead bolt.

continued c page
Liza King
Noel Wolf Petersen
DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/18/2026
NARRATIVE
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The facility is going to do some some significant renovations on the exterior and interior: kitchen, dining room, concrete pours on the front side and back of the house. Of concern to licensing is the access to the bedrooms and regular services(meals), the LPA gave guidance that the licensee may want to issue 60 day notices to the current clients and temporaily suspend the license for the renovations. LPA gave guidance that he would email supplemental information about license suspension .

3 clients medication and mar logs were checked at random. LPA reviewed facilities process of documentation for refusals, PRNs, and Destruction record. 1 log had 3 missing medications, with rotine orders, 2 mediction was missing(prn pain relif), 1 medication was being given without an order(prn for sleep) files are otherwise are in accord with physical medication, employees are knowlegeable about facility processess.

3 client files were reviewed for the health screenings, needs and services plan, recent and starting 602/603 medical assessments, and signed admission agreements. 1 client appears to have 2 rate increases without notification, 1 from 2500 to 3000 in february 2024 and one from 3000 to 3200 in June of 2026. files are otherwise present and up to date.

3 staff files were reviewed for the health screeninigs, backround checks, recent and starting trainings, and firstaid/cpr training. 3 of 3 staff files dont have annual training from 2025 and only 2-4 hours of training for 2026. 3 of 3 staff have a first aid card with a name and and a date, 1 of 3 have a first aid card with a issuing entity that can be verified. LPa gave guidance to ensure verification of first aid, and not to have a staff work a shift alone with somebody who does not have verified first aid. files are otherwise present and up to date.

Administrator file was reviewed for the admin certificate, facility license, required posters(personal rights, ombudsman. files are present and up todate.

3 clients were interviewed, 2 staff were interviewed

fire extinguisher is dated 1/19/26. smoke/CO alarm is functional. first aid kit is missing a thermometer, all required items otherwise.

citations associated with this visit. appeal rights were provided. A copy of the report was read and given to the administrator. exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/18/2026 04:56 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 08/18/2026 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST. STEPHEN'S HOME
FACILITY NUMBER: 502700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record Review, where one resident(r1) was missing 3 routine medications from her MAR sheet, the licensee did not comply with the section cited above in 1 out of 3 MAR sheets reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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LPA suggests, Licensee should self audit all the clients medications, if mars are missing medications they should be added, if there is cause to call a doctor and get a new medication to address a need that should be done, if there are missing medications that there is an order for, those medications should be ordered. A inventory of each residents medications should be sent to the LPA with pictures of containers for each medication, end of day 8/19 due
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review where two residents were missing tylonal pain medication(r1 missing 325mg and r2 missing 500mg), and Interview with staff where one resident(r2 only) being given melatonin without a perscribed order. the licensee did not comply with the section cited above in 2 out of 3 medications/mars reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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LPA is suggesting, the licensee/administratior add herself to a training on medication administration mangement, conducted by a 3rd party.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/18/2026 04:56 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 08/18/2026 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST. STEPHEN'S HOME
FACILITY NUMBER: 502700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87706(a)(1)(C)
Advertising Dementia Special Care, Programming, and Environments
(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: (1) In addition to the requirements specified in Sections 87208, Plan of Operation, the licensee shall include in the plan of operation a brief narrative description addressing the following additional information: (C) Staff training describing the required training for direct care staff who provide dementia special care. At a minimum, the description shall include information on training to be provided, as specified in Health and Safety Code sections 1569.625 and 1569.626.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 3 staff files did not meet the hours requirements in 2025 for 12 hours of standard annual training topics or 8 hours of dementia specific topics. licensee did not comply with the section cited above in 3 out of 3 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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LPA suggest the Liceensee send a plan of future trainings, that discribes topics and timelines for the employees to meet thier annual training goals. due 8/25/26

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/18/2026 04:56 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 08/18/2026 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST. STEPHEN'S HOME
FACILITY NUMBER: 502700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Observation, the lpa did not observe a chair in 4 out of 5 clients rooms. the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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LPA suggest chairs be added to the rooms.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of the evacuation route gate path way there are 3 gates which drag into the ground and 1 resident in a wheelchair, the licensee did not comply with the section cited above in 3 out of 3 evacuation route gates which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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LPa suggests either griding down the gates or rehanging them such that they swing freely and latch closed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/18/2026 04:56 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 08/18/2026 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST. STEPHEN'S HOME
FACILITY NUMBER: 502700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.655(a)
Other Provisions
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of 1 admission agreement, 2 related invoices, and 1 notification it appears two rases in rent occured for r3, one in 2/2024 from 2500 to 3000 without notification or outlying reason or reasons for the increase and a second in 6/2026 from 3000 to 3200, which did have a notification put was dated 2 days prior, also did not outlay the reason or reasons for the increase. the licensee did not comply with the section cited above in 1 out of 3 client records reviewed which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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LPA suggested Licensee should review t22 procedure for rate increases in an RCFE and send a signed copy of the regulation to the LPA by the POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
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