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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701255
Report Date: 03/02/2023
Date Signed: 03/02/2023 11:24:14 AM

Document Has Been Signed on 03/02/2023 11:24 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ST MARY'S HOMEFACILITY NUMBER:
502701255
ADMINISTRATOR:ALMENDRALA, MARIAFACILITY TYPE:
740
ADDRESS:2800 CATALA WAYTELEPHONE:
(650) 267-3248
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 3DATE:
03/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria AlemdralaTIME COMPLETED:
11:45 AM
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On 03/02/2023 at 10:00am, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a Pre-Licensing Visit. LPAs were greeted by the Facility Designated Administrator, Maria Almendrala and explained the purpose of the visit. The purpose of this visit was to conduct a Pre-Licensing Visit due to a change of ownership. This facility has a Dementia Program on file and a hospice waiver for 6.
Current census was 3. There were two other staff members present during this visit, Mae Pascual and Jennifer Coburn. LPAs intiated tour of the facility with FDA Alemdrala.
The fire extinguisher, located in the kitchen area, was purchased on 03/01/2023 and had a receipt attached at this time. Carbon monoxide and fire alarms were present and in good repair.
Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance.
A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Grab bars were present and functional.
Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition.
A linen closet was located in the hallway. LPAs observed a sufficient amount of linens at this time.
The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. A tour of the pantry was conducted. LPAs observed that there was a 7-day nonperishable food supply at this time.
Garage area was toured.
This facility will be using a medication cart which was located in the living room. LPAs observed the medication cart to be locked and made inaccessible at this time.
First aid kit was observed to be present and contained all of the required components at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MARY'S HOME
FACILITY NUMBER: 502701255
VISIT DATE: 03/02/2023
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Exterior grounds of this facility was toured.
Perimeter fence and gates were observed to be functional and in good repair at this time.
This facility has been observed to be in compliance at this time.

There were no deficiencies observed during the course of this Pre-licensing visit.

Component III will be waived at this time.

Exit Interview was conducted and a copy of this report was provided to the Facility Designated Administrator at the end of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC809 (FAS) - (06/04)
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