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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700908
Report Date: 10/10/2025
Date Signed: 10/14/2025 11:37:01 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2025 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250610161834
FACILITY NAME:ST. TIMOTHY'S HOMEFACILITY NUMBER:
392700908
ADMINISTRATOR:ALMENDRALA, MARIAFACILITY TYPE:
740
ADDRESS:9230 LARIAT LANETELEPHONE:
(650) 267-3248
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 5DATE:
10/10/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Avia SinghTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident developed a pressure injury due to neglect.

Facility didn't seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 10/10/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person, Avia Singh, who was briefly interviewed at this time. This LPA requested that this facility staff person go ahead and contact the facility designated Administrator, Maria Almendrala, to inform her that CCL was present at this time.
This LPA was informed that the facility designated Administrator would not be able to be present for todays complaint visit and allowed the present facility staff person to accept all documents related to this complaint at this time.
Current census was 5 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility, and it's representative, at this time.
Based on a review of the forms and documents related to this investigation, it was learned that R1 had several medical issues requiring care and supervision related to R1's mental and physical conditions. The mental health conditions required the facility staff to be present and available to assist with R1's daily issues
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20250610161834
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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. TIMOTHY'S HOME
FACILITY NUMBER: 392700908
VISIT DATE: 10/10/2025
NARRATIVE
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of wandering, elopement, and stimulation in order to engage and maintain proper quality of life unto R1.
In addition, it was learned that R1 had several physical conditions which required staff to check up on R1 with R1's Activities of Daily Living (ADLs), medication management, and proper documentation of any changes to R1's overall status in order to address them and integrate new policies and procedures.
Based on a review of the medical records for R1, it was learned that R1 was sent to the local medical facility on several dates requiring extensive treatment and follow up with hospice and wound care.
It was learned that in the month of December 2024, R1 was seen at the local medical facility for severe sepsis due to an infected wound that required adequate cleaning and a prescription for antibiotics. Follow up visits were conducted to the local medical facility for R1 in regards to the same issue of sepsis and was even admitted to the local skilled nursing facility as well for treatment and labs.
It was learned that several admissions were also made in the month of January 2025 for the same medical issue related to severe sepsis for R1 with the discovery of a Stage IV pressure ulcer as well to the sacrum area. Upon discovery of the Stage IV pressure ulcer, it was initially deemed to be unstageable since the scar tissue was thick and the ulcer was unable to be evaluated at that time for proper assessment. A licensed medical professional was tasked to clean and clear the wound area for R1. It was learned that R1 was then discharged from this local medical facility with a referral for wound care and another one for hospice care.
Based on a review of the forms and documents conducted during the course of this investigation, it was learned that proper notifications were not given to the family or responsible parties for R1 in regards to the hospital visits and changes to R1's medical conditions.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated representative at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250610161834
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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. TIMOTHY'S HOME
FACILITY NUMBER: 392700908
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2025
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or
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The facility designated representative stated that this facility will implement a training regiment to address the topic of resident observation, documentation of such changes, and reporting to the appropriate responsible parties and entities in order to facilitate proper care and supervision to the residents
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a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This facility was found to be deficient as evidenced by repeated visits to the local medical facility for a resident exhibiting the same medical issues eventually resulting in more serious health conditions which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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in care.
Proper training regiment will include the name of the trainer, topics of training, and a list of the attendees. This training will be conducted for no less than (1) hour in duration.
Proof of training will be completed and submitted into CCL by the due date.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250610161834
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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. TIMOTHY'S HOME
FACILITY NUMBER: 392700908
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2025
Section Cited
CCR
87615(a)(1)
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Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

(1) Stage 3 and 4 pressure injuries.
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The facility designated representative stated that this facility will implement a training regiment to address the topic of Prohibited Health Conditions and how this facility should address this issue with the residents in care.
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This facility was found to be deficient as evidenced by the retention of a resident diagnosed with a Stage IV pressure ulcer which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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Proper training regiment will include the name of the trainer, topic of training, and a list of the attendees. This training will be conducted for no less than (1) hour in duration.
Proof of training will be completed and submitted into CCL by the due date.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4