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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700261
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:53:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220209154642
FACILITY NAME:ST. STEPHEN'S HOMEFACILITY NUMBER:
502700261
ADMINISTRATOR:ALMENDRALA, MARIAFACILITY TYPE:
740
ADDRESS:1309 OAKWOOD DRIVETELEPHONE:
(209) 488-4901
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 6DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Maria AlmendralaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident fell and sustained a fracture
Unlawful eviction
INVESTIGATION FINDINGS:
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On 5/5/2022, Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to complete a complaint investigation regarding the above allegations. LPA Lund meet with care staff and explained the reason for the visit. Staff called Administrator Maria Almendrala and arrived sometime later.

LPA Lund reviewed facility records interviewed staff and witnesses regarding the above allegations.

Based on interviews with staff & witness and record review. According to Unusual Incident/ Injury Report (LIC624) dated 6/6/2021, Resident (R1) lost balance and fell on R1’s left side and 911 was called and was sent to the Emergency Room (ER). The report failed to state that R1 broke R1’s femur. When R1 returned to the facility on 6/23/2021. The facility failed to a plan for R1 being a fall risk. On 7/8/2021 R1 fell on the floor and 911 was called and was sent to the ER. R1 had surgery on and returned back to the facility on 7/23/2021.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220209154642

FACILITY NAME:ST. STEPHEN'S HOMEFACILITY NUMBER:
502700261
ADMINISTRATOR:ALMENDRALA, MARIAFACILITY TYPE:
740
ADDRESS:1309 OAKWOOD DRIVETELEPHONE:
(209) 488-4901
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 6DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Maria AlmendralaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Resident being charged for services not rendered
Resident not administered medication as prescribed
INVESTIGATION FINDINGS:
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LPA Lund interviewed staff, witness and reviewed facility records regarding the above allegations.

Based on interviews with witness, staff and review of records on 6/24/2021 the facility mailed and spoke with Resident (R1’s) daughter stating that rate change went from $2000 to $2500. The reason for the change was the level of care and R1 needed from a shared room to a non-ambulatory room.

It was learned through interviews with staff, witness and records review, R1 has seizures and takes medication for the seizures. R1’s Medication Administration Record (MAR) states that the facility administered R1 seizure medication as prescribed for the periods of 6/1/2021 through 2/6/2022.


Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220209154642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ST. STEPHEN'S HOME
FACILITY NUMBER: 502700261
VISIT DATE: 05/05/2022
NARRATIVE
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As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator Maria Almendrala and a copy of report and a copy of the appeal rights was given to Administrator Maria Almendrala.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20220209154642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ST. STEPHEN'S HOME
FACILITY NUMBER: 502700261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator Maria Almendrala will look over the regulation and email LPA Lund understanding of the regultion.
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This requirement is not met as evidenced by: The facility failed to proper report the incident on the UIR and didn't an proper fall risk plan. which poses an immediate risk to residents in care.
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Type B
05/19/2022
Section Cited
CCR
87224(d)
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The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
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Administrator Maria Almendrala will look over the regulation and email LPA Lund understanding of the regultion.
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This requirement was not met as evidenced by: The facility failed to give proper 30-day notice to R1. This poses a potential health and safety risk to residents in care.
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220209154642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ST. STEPHEN'S HOME
FACILITY NUMBER: 502700261
VISIT DATE: 05/05/2022
NARRATIVE
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It was learned through interviews with staff and witness, that R1 has seizures and takes medication for the seizures. On 1/27/2022 R1 has a seizure and was sent to the ER and then admitted to the hospital. While admitted to the hospital, Licensee Maria Almendrala communicated with R1’s daughter stating that R1 could not come back to the facility and the hospital would find proper placement for R1. R1 was never given a 30-day notice from the facility. The facility failed to give proper 30-day notice to R1.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5