502701255-7-31-2023-27-AS-KVIA-CU9VD2-20230731162000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701255
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:20:05 PM

Document Has Been Signed on 07/31/2023 04:20 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ST MARY'S HOME		FACILITY NUMBER:	502701255
ADMINISTRATOR:	ALMENDRALA, RICHIE		FACILITY TYPE:	740
ADDRESS:	2800 CATALA WAY		TELEPHONE:	(650) 267-3248
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS: 6	DATE:	07/31/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Maria Almendrala		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/31/2023, unannounced post licensing visit made to this facility by Licensing Program Analyst (LPA) Kimberly Viarella. LPA identified herself and the purpose of her visit to the staff who greeted her at the door. Maria Almendrala, wife of the Licensee / Administrator was called and arrived at the facility shortly after. She has also completed the administrator's certification program (# 6041853740, payment received 02/13/2023). LPA provided the steps to changing the Administer of record from Richie Almendrala to Maria Almendrala. LPA performed an inspection of the common areas and bedrooms; all had the required furniture, furnishings and lighting to be in compliance. LPA observed numerous ants in one of the bedrooms. The Designated Administrator called their pest control vendor to arrange for a treatment. LPA inspected the kitchen and noted that 4 out of 4 containers in the refrigerator were not labeled. Caregiver immediately cleaned out the refrigerator and labeled all containers. Food supply was reviewed to make sure that there was an adequate supply of 2-day perishable and 7-day nonperishable quantities at all times. LPA measured the Hot water to ensure it was between 105 and 120 degrees Fahrenheit. Medications were locked and inaccessible to residents. LPA reviewed policies and procedures regarding storage, dispensing, and destruction as well as the regulations and Medication Guidelines with the Designated Facility Administrator. Currently the facility was home to 1 bedridden resident. This resident was admitted as non-ambulatory and their status changed after they returned from the hospital. The Designated Facility Administrator completed an LIC 200 to request a change to their license to include bedridden.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ST MARY'S HOME	FACILITY NUMBER: 502701255
	VISIT DATE: 07/31/2023

NARRATIVE

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Component III was reviewed with the Designated Facility Administrator.

The following documents were requested to be sent to CCL:

Copy of Liability Insurance

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/31/2023 04:20 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 07/31/2023 at 02:39 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ST MARY'S HOME	FACILITY NUMBER: 502701255
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation 87303(a) The facility shall be clean safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in when the LPA observed ants on the bed and floor of a residents's bedroom where there were crumbs attracting the insects. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Licensee will have pest control visit the facility and provide a treatment by the above due date and will submit proof of treatment to kimberly.viarella@dss.ca.gov. The Licensee will also have someone repair the switch plate and kickplate to the door off of that room in order to prevent insects entry.

Type B

Section Cited

CCR

87555(b)98)

Food Storage (b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when 1 out of 3 items pulled from the refrigerator were expired and 4 out of 4 items that were wrapped in plastic or were in storage containers were not labeld and dated. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Licensee will develop a monthly schedule for cleaning the refridgerator so that expired goods will be disposed of immediately. This schedule will be submitted to kimberly.viarella@dss.ca.gov. by 08/04/2023.

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:

Liza King

LICENSING EVALUATOR NAME:

Kimberly Viarella

LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

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