St Mary's Home

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 04/15/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Maria Almendrala who arrived shortly thereafter to this facility after being called by the facility caregiver. A brief interview was conducted with the facility designated Administrator at this time. Current census was 6 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 03/11/2026. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 03/11/2026: 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. 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). 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. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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. 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. 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. All window screens shall be clean and maintained in good repair. 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: Plan of Correction clearance letters were printed and copies were provided to the facility designated representative at this time. 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 copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 17, 2026

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: 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.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: 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 of visit: Required - 1 Year

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. 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 Interviewthe state’s words, verbatim · CDSS document, Mar 11, 2026

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Required - 1 Year

On 2/29/24 at approximately 9:50am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Maja Jensen met with Administrator Maria Alemndrala and explained the purpose of today's visit. The Administrator holds current Administrator's certificate # 7012579740 good through 09/28/2024. LPA Jensen toured the grounds and observed them to be well maintained and all paths were free of obstruction. There are no bodies of water on the property. LPA Jensen toured the interior. All required postings were observed to be posted in easily viewable locations. There are 3 double occupancy bedrooms. The current census is 6 with 1 resident on hospice. LPA Jensen observed 1 resident to have a bed with full bed rails for which there no physician's order on file. Technical assistance was provided. There was adequate lighting throughout. The thermostat was set at 74 degrees Fahrenheit which falls within the required regulatory range of 68 degrees to 85 degrees. The bathrooms were equipped with grab bars and there was non-slip flooring in the bathtub. The facility maintains adequate linens and grooming supplies. The water temperature was measured at 122 degrees Fahrenheit and "caution - hot water" signs are posted. LPA Jensen toured the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was no expired food observed. Knives, medications and cleaning supplies were observed to be locked and inaccessible to residents in care. The first aid kit was observed to be complete and in compliance. The fire extinguisher was last serviced on 3/2/23 and is in compliance. The carbon monoxide detector and smoke detector were tested and found to be in good working order. The facility conducts and records regular fire drills. There is an emergency supply of water and lighting. LPA Jensen checked did a random audit of medication and observed a medication prescribed for resident 1 was not documented on the Centrally Stored Medication and Destruction Record. LPA Jensen reviewed 2 staff files and determined them to be in compliance. LPA Jensen reviewed 6 of 6 resident files and determined them to be complete and in compliance. LPA Jensen requested a copy of the LIC 500 and liability insurance. The Administrator advised that the liability insurance is pending. LPA Jensen reviewed a letter from Arthur Gallagher Risk Management Services that state the Licensee has applied for iability insurance that will comply with AB1523. The inspection tool was used during the course of this visit. LPA Jensen completed the physical plant inspection, left the facilty for lunch for 45 minutes and returned to conduct file reviews. A deficiency is being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 29, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.