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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701255
Report Date: 03/11/2026
Date Signed: 03/12/2026 09:57:44 AM

Document Has Been Signed on 03/12/2026 09:57 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 HOMEFACILITY NUMBER:
502701255
ADMINISTRATOR/
DIRECTOR:		ALMENDRALA, RICHIEFACILITY TYPE:
740
ADDRESS:2800 CATALA WAYTELEPHONE:
(650) 267-3248
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
03/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Lema Arficho, Barry Francis, and Maria AlmendralaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 03/11/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility caregivers, Lema Arficho and Barry Francis, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator, Maria Almendrala, to inform her that CCL was present at this time. The facility designated Administrator, Maria Almendrala, arrived shortly thereafter to this facility while this LPA was conducting this annual visit.
Current census was 6 residents, of which (1) resident, was out of the facility at this time in the hospital. It was learned that there were (3) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time.
It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (4) residents diagnosed with dementia at this time. It was learned that there weren't any residents receiving services through home health at this time. It was learned that this facility does not have a bedridden fire clearance to be able to accept or retain any residents deemed to be bedridden at any given time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
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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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 MARY'S HOME
FACILITY NUMBER: 502701255
VISIT DATE: 03/11/2026
NARRATIVE
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Garage area was toured. Laundry area, located next to the garage area, was toured and observed to be locked at this time. A review of the bleach, detergent, and all other cleaning supplies was conducted to make sure that they were locked and made inaccessible to the residents at this time.
Administrator certificate # 7012579740 for Maria Almendrala was observed to have an expiration date of 09/28/2026 and in compliance at this time.
Medication cabinet, located in the facility office cart, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the facility office, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher located hanging on the wall adjacent to the kitchen was observed to have been annually inspected by the local fire extinguisher company, Touch Down Fire, with the inspection date of 01/19/2026 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (4) facility personnel records was conducted and noted on the following LIC 859.
A review of (6) facility resident records was conducted and noted on the following LIC 858.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:
LIC 308
LIC 400
LIC 500
LIC 610
The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
Appeal Rights were printed and a version was given to the facility designated Administrator at this time.
Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2026 09:57 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/11/2026 at 12:42 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 MARY'S HOME
FACILITY NUMBER: 502701255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the flooring in the common areas and some resident bedrooms were in need of being repaired/replaced since the planks were starting to slide and separate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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The facility designated Administrator stated that a bid will be obtained in order to determine the severity of the damage and overall cost to repair/replace the facility flooring in the common areas and resident bedrooms. A statement of correction, along with proof of contracted bid for the flooring services to repair/replace, will be completed and submitted into CCL for review by this LPA.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water measured in a resident restroom faucet was found to be at 124.2 degrees which was above the allowed range which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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The facility designated Administrator stated the hot water heater will be turned down and the hot water dispensed will be measured for the next (3) days at various times of the day (AM, PM, and NOC shift) in order to make sure that the temperatures are all within the allowed range of 105-120 degrees at all times. A statement of correction, along with documented proof of the hot water temperatures taken over the next (3) days, will be completed and submitted into CCL.
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:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2026 09:57 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/11/2026 at 12:42 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 MARY'S HOME
FACILITY NUMBER: 502701255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health 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. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 that [2] out of [4] facility staff files did not contain updated TB clearance on their health screenings which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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The facility designated Administrator stated that an audit of all of the facility staff files will be conducted to make sure that the medical assessments are complete and up to date. A statement of correction, along with copies of the updated medical assessments with clearance for TB for the facility staff will be completed and submitted into CCL for review by this LPA by the due date.

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:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/12/2026 09:57 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/11/2026 at 12:42 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 MARY'S HOME
FACILITY NUMBER: 502701255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in [1] out of [4] facility staff did not have updated first aid training certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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The facility designated Administrator stated that an audit of all of the facility staff files will be conducted to make sure that the first aid training is complete and up to date for all staff. A statement of correction, along with copies of the updated first aid training for the facility staff will be completed and submitted into CCL for review by this LPA by the due date.
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that the pantry area was reviewed and there was not a sufficient supply of non perishable food items to satisfy the 7-day quantities on hand at all times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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The facility designated Administrator stated that a review of the current non perishable food supply will be conducted and additional food items will be purchased to make sure that this facility maintains, and has on hand at all times, a sufficient supply of 7-day non perishable food items. A statement of correction, along with a receipt of the updated food purchase for non perishable food items, will be completed and submitted into CCL for review by this LPA by the due date.
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:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/12/2026 09:57 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/11/2026 at 12:42 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 MARY'S HOME
FACILITY NUMBER: 502701255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in that [2] out of [6] facility resident files did not have a complete and updated medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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2
3
4
The facility designated Administrator stated that an audit of all of the facility resident files will be conducted to make sure that the medical assessments are complete and up to date. A statement of correction, along with copies of the updated medical assessments for the facility residents will be completed and submitted into CCL for review by this LPA by the due date.
Type A
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [6] facility resident files did not have updated and proper TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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2
3
4
The facility designated Administrator stated that an audit of all of the facility resident files will be conducted to make sure that the medical assessments are complete and up to date. A statement of correction, along with copies of the updated medical assessments with clearance for TB for the facility residents will be completed and submitted into CCL for review by this LPA by the due date.
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:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2026 09:57 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/11/2026 at 12:42 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 MARY'S HOME
FACILITY NUMBER: 502701255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 that several window screens and sliding glass door screens were in need of repair/replacement containing holes, tears, and rips in them. Some sliding glass door screens were offline and needed to be realigned which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that an audit of all window screens and sliding glass door screens will be reviewed to make sure that they do not have any holes, rips, or tears in them. Also any misaligned sliding glass door screens will be repaired and realigned to make sure that they are able to be used and handled by the facility residents in opening/closing them. A statement of correction, along with contracted work for the repairs/replacements of the screens will be completed and submitted into CCL for review by this LPA by the due date.
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [1] out of [4] facility staff did not have updated training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that an audit of all facility personnel files will be conducted to make sure that all associated facility staff providing care and supervision to the residents in care and adequately trained and updated for annual training hours at all times. A statement of correction, along with updated hours of annual training, will be completed and submitted into CCL for review by this LPA by the due date.
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:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
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