502701255-4-4-2024-27-AS-MJEN-D3ZKGJ-20240404075334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701255
Report Date: 02/29/2024
Date Signed: 04/04/2024 07:54:28 AM

Document Has Been Signed on 04/04/2024 07:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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:	02/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Maria Almendrala		TIME COMPLETED:	04:00 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 2/29/24 at approximately 9:50am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Maja Jensen met with Administrator Maria Alemndrala and explained the purpose of today's visit. The Administrator holds current Administrator's certificate # 7012579740 good through 09/28/2024. LPA Jensen toured the grounds and observed them to be well maintained and all paths were free of obstruction. There are no bodies of water on the property. LPA Jensen toured the interior. All required postings were observed to be posted in easily viewable locations. There are 3 double occupancy bedrooms. The current census is 6 with 1 resident on hospice. LPA Jensen observed 1 resident to have a bed with full bed rails for which there no physician's order on file. Technical assistance was provided. There was adequate lighting throughout. The thermostat was set at 74 degrees Fahrenheit which falls within the required regulatory range of 68 degrees to 85 degrees. The bathrooms were equipped with grab bars and there was non-slip flooring in the bathtub. The facility maintains adequate linens and grooming supplies. The water temperature was measured at 122 degrees Fahrenheit and "caution - hot water" signs are posted. LPA Jensen toured the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was no expired food observed. Knives, medications and cleaning supplies were observed to be locked and inaccessible to residents in care. The first aid kit was observed to be complete and in compliance. The fire extinguisher was last serviced on 3/2/23 and is in compliance. The carbon monoxide detector and smoke detector were tested and found to be in good working order. The facility conducts and records regular fire drills. There is an emergency supply of water and lighting.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST MARY'S HOME	FACILITY NUMBER: 502701255
	VISIT DATE: 02/29/2024

NARRATIVE

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LPA Jensen checked did a random audit of medication and observed a medication prescribed for resident 1 was not documented on the Centrally Stored Medication and Destruction Record. LPA Jensen reviewed 2 staff files and determined them to be in compliance. LPA Jensen reviewed 6 of 6 resident files and determined them to be complete and in compliance.

LPA Jensen requested a copy of the LIC 500 and liability insurance. The Administrator advised that the liability insurance is pending. LPA Jensen reviewed a letter from Arthur Gallagher Risk Management Services that state the Licensee has applied for iability insurance that will comply with AB1523. The inspection tool was used during the course of this visit. LPA Jensen completed the physical plant inspection, left the facilty for lunch for 45 minutes and returned to conduct file reviews.

A deficiency is being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 04/04/2024 07:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST MARY'S HOME	FACILITY NUMBER: 502701255
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's review of the Centrally Stored Medication and Destruction Record in comparison to medication on hand, the licensee did not comply with the section cited above in 1 of 1 count which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to document Centrally Stored Medication and Destruction Record with all Medications noting the date they are filled and started.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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