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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701255
Report Date: 02/12/2025
Date Signed: 02/12/2025 12:52:15 PM

Document Has Been Signed on 02/12/2025 12:52 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 MARY'S HOMEFACILITY NUMBER:
502701255
ADMINISTRATOR/
DIRECTOR:		ALMENDRALA, RICHIEFACILITY TYPE:
740
ADDRESS:2800 CATALA WAYTELEPHONE:
(650) 267-3248
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 3DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Maria Almendrala, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 02/12/2025.  LPA met with Maria Almendrala, Assistant Administrator and explained the purpose of the visit. Upon entry, LPA Campbell observed a See Something Say Something poster and the ombudsman information poster near the door. A sign in sheet was observed near the door along with a bottle of sanitizer and masks. Signs in windows near the entrance notified guests that Oxygen was in use. LPA Campbell was greeted by Caregiver Indesha Robinson. Two clients were in the living room watching TV or conversing with staff. LPA Campbell introduced themselves and inquired about their well being. Both clients were alert and stated they were well.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) non-ambulatory residents, and six (6) hospice waiver clients.  LPA Campbell observed the facility to be free of odor, clean, well lit and in good repair. The thermostat was set to 72 degrees Fahrenheit (F). LPA Campbell observed the 4 bedrooms to be properly furnished with appropriate accessories (lamp, bed, nightstand, drawers) bedding and lighting. There are no bodies of water present. The backyard contained shade, seating and no debris. The fire exit was clear of obstructions.
The fire extinguisher was last inspected on 01/15/2024 and is currently fully charged. Smoke alarms were were tested and found to be functioning.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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Document Has Been Signed on 02/12/2025 12:52 PM - It Cannot Be Edited


Created By: Renee Campbell On 02/12/2025 at 11:08 AM
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 MARY'S HOME
FACILITY NUMBER: 502701255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
87411(f) Personnel Requirements - General. All personnel ...shall be....verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 4 personnel files reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator will review regulation 87411 and present a statement of understanding to LPA Campbell via email. Provide proof of negative TB tests for S1 and S2. Audit all files to ensure they were completed in full by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


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: 02/12/2025
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When asked how many staff were able to work in the facility, Maria Almendrala stated there were four staff. Staff 1(S1) was found to have an incomplete Personnel Record, no health screening and no TB test. Per the Administrative Assistant, S2 had not been able to schedule their TB or health screening since being hired in January. During the course of the visit, Administrative Assistant Maria Almendrala removed the staff who had not had their TB tests.

For the three clients remaining, Mara Almendrala was to able to take over supervision with assistance from staff added to the roster from another facility (S3) as observed by the LPA. LPA Campbell confirmed with the Assistant Administrator the that S1 and S2 should not return until at least tomorrow without their completed chest x-rays and health screening.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit.  An exit interview was conducted, and copies of the report and appeal rights left. 
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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