St. Stephen's Home

Type of visit: Required - 1 Year

Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to conduct annual visit. The LPA met with the administrator Maria Almendrala to explain the purpose of the visit. St.Stevens home is a 6 bed facility licensed for 3 ambulatory and 3 non ambulatory with a maximum of 2 hospice clients. 1 client is currently on hospice, 1 client has dementia, 1 client has major neurocognative disorder. Physical inspection was conducted, including but not limited to the bedrooms, bathrooms, kitchen, common areas, exterior and evacuation route gates. facility is clean, traffic areas are well lit. ~Kitchen has lockable storage for sharps, medications, toxics, LPA observed the lock off of the sharps drawer, it was not unattended. 1 clients access to sharps are suspect. there is adequate food for 2 days perishable, 7 days non perishable meals. LPA gave guidance that the bulk foods in containers (rice/cereals should have their labels of the orginal packaging stored with the items.) ~Bedrooms have mostly all required furniture and furnishings, including mattress encasements. LPA observed 4 bedrooms without chairs. LPA observed 2 beds equipped with half rails. LPA gave guidance the bedrails should be removed if the residents do not have an order from a doctor. LPA observed oxygen tank in Bedroom, the client doesn't require oxygen. LPa gave guideance to not use client bedrooms as storage. ~Bathrooms have hardware in good repair, the water temp measured at the basin is 121*F. Water heat was downadjusted while the LPA was in the facility, LPA gave guidance to set the heater between 110 and 115 to account for seasonal variation. ~Common/Exterior Areas, there is adequate space for activities. 5 residents were watching tv when the LPA arrived, 1 resident was listening to classical music ~evacuation Routes Gates, do not swing freely and latch closed. Three out of three gates drag into the concrete, LPA observed that the fence shared with the eastward neighbor is significantly out of repair and has missing boards, posts connected to nothing, and may ultimately be the cause of the gates dragging into the ground. LPA observed a deadbolt for the emergency gate, LPA gave guidance to remove the dead bolt. continued c page The facility is going to do some some significant renovations on the exterior and interior: kitchen, dining room, concrete pours on the front side and back of the house. Of concern to licensing is the access to the bedrooms and regular services(meals), the LPA gave guidance that the licensee may want to issue 60 day notices to the current clients and temporaily suspend the license for the renovations. LPA gave guidance that he would email supplemental information about license suspension . 3 clients medication and mar logs were checked at random. LPA reviewed facilities process of documentation for refusals, PRNs, and Destruction record. 1 log had 3 missing medications, with rotine orders, 2 mediction was missing(prn pain relif), 1 medication was being given without an order(prn for sleep) files are otherwise are in accord with physical medication, employees are knowlegeable about facility processess. 3 client files were reviewed for the health screenings, needs and services plan, recent and starting 602/603 medical assessments, and signed admission agreements. 1 client appears to have 2 rate increases without notification, 1 from 2500 to 3000 in february 2024 and one from 3000 to 3200 in June of 2026. files are otherwise present and up to date. 3 staff files were reviewed for the health screeninigs, backround checks, recent and starting trainings, and firstaid/cpr training. 3 of 3 staff files dont have annual training from 2025 and only 2-4 hours of training for 2026. 3 of 3 staff have a first aid card with a name and and a date, 1 of 3 have a first aid card with a issuing entity that can be verified. LPa gave guidance to ensure verification of first aid, and not to have a staff work a shift alone with somebody who does not have verified first aid. files are otherwise present and up to date. Administrator file was reviewed for the admin certificate, facility license, required posters(personal rights, ombudsman. files are present and up todate. 3 clients were interviewed, 2 staff were interviewed fire extinguisher is dated 1/19/26. smoke/CO alarm is functional. first aid kit is missing a thermometer, all required items otherwise. citations associated with this visit. appeal rights were provided. A copy of the report was read and given to the administrator. exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: resident was not assisted with medications as ordered

Licensing program Analyst, LPA, Noel Wolf Petersen arrived to the facility at 10:30am to conduct a complaint investigation into alleged violation above. Met with the staff and then the administrator Maria Almendrala by phone to explain the purpose of the visit As to the allegation that a resident was not assisted with medications as ordered, R1 made a statement that their Mar records were falsified and their morphine medication was not distributed as perscribed. a statement from the administator was made regarding R1 that the morphine order was made for PRN pain management, and that the staff did not find signs and symptoms for pain, and therefore there were times when the staff did not distribute the medication. Several elements in the record review of documents were presented: Continued on c. page Substantiated ~In R1's MAR there was an order for perscribed morphine in tablet form which is filled out as distributed appropriately according to the order, ~In the resident R1's discharge notes from 5/7/26 Almond Vista, the prescription reads as 1 per 12 hours, no modulation asterisks for a hold, no language indicates an "as needed" basis. ~In record review, it was learned that S1 had filled out at least one MAR(R4) log with entry's where they described themselves as being out of the facility, in interview S1 stated they had falsely entered into the MAR that they had distributed medication when it was not them who distributed the medication, and was not here in the facility to witness if the medication was distributed. ~602 for the resident indicates the ability to administer their own medication, not being coginatively impaired, and the ability to commuicate needs, and past medical history indicates multiple sources of chronic pain (fractures) ~Needs and services plan, indicates R1 needed all ADL's assistance due to pain ~The controlled substances log does not have a morphine entry ~ A record review of the MARs of 5 clients can't support the missing medications for any resident, but also is being filled out by a staff after the fact, difficult to tell whats true Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.) Citation was issued on the following D page, a copy of the report was read and given to the staff designated by the administrator. appeal rights provided, an exit interview was conducted. As to the allegation that the staff do not speak to residents in a respectful manner, it was reported by r1 that staff were rude to them and other clients, when the staff discontinued thier percocet medication the client was told "Nobody needs that" by S1, R2 was yelled at to change clothes and take a shower by S3, and R3 was yelled at when they would smoke in the bathroom. S3 and R3 were unavailible for interview by the LPA. R2 did not corroberate being yelled at. S1 reported R4 and R3 being upset occassionally and using some racist terms to the staff. R4 had heard R3 and a staff he did not identify going back and fourth in an argument where both sides were shouting. 2 of 6 residents agreed to the statement that staff do not speak to residents in a respectful manner. as to the allegation that the facility limited access to the community, it was reported by r1 that they and r2 were not allowed to go more than down the slope of the entry ramp by S3. It was further reported by r1 that they were prohibited by the staff(s3) from going to the pharmacy or her doctors office, to the degree of turning away the dial a ride service R1 had arraanged for transprot. It was further reported by r1 that they were prohibited from attending church services. Record review of the 602 for R1 indicated they were able to leave the facility unassisted "with family". No documentation was made, so it is unclear that distinction was ever explained by the facility to the resident, or that an effort was made to address the expressed pharmacological or religious needs of the resident. S1 and the admin both reported that the resident never was denied access to the community inappropriately. Admin reported that the dial a ride service was being charged to the facility rather than the resident, and there was a misscommunication between the facility and the resident about why they were not allowed to make use of the dial a ride service in that particular instance. 2 of 6 of the residents agreed with the statement that they had experinced an issue with accessing the community. As to the allegation that staff did not reorder residents medications timely: R1 reported that S1 was instructed by the administrator to hold off on telling them when a medication was about to run out until after normal buisness hours of thier perscribing doctor. R1 further reported that there were resulting periods where the facility was not able to deliver all medication as perscribed, and due to the delay in reciving a particular pain management medication from the staff, R1 took it upon themselves to either arrange transport to the emergency department to recive pain managment medication or arrange for thier perscribing doctor to make the medication availible at the pharmacy for pick up. R1 further reported that the administrator did not act to pick up the medication from pharmacy when it was availible and limited access to the community ofthe client to leave the facility to pick up the medication. Continued on C2 The administrator, in interview denied refusing to pick up a medication that was availible. In staff interviews, S1 provided the statement that residents (r1, r4)medications were occasionally delivered late by the pharmacy, but not as a result of the facility failing to order the medication timely or being instructed to delay ordering a medication. In record review, there is no log of care notes available describing phone calls staff made on behalf of the residents to the pharmacy. The MAR for 5 clients doesn't indicate gaps for medication distribution, but additional details bring the utility and truthfulness of the MAR into question on the substantiated allegation associated with this complaint. 1 family member FM1, indicated that they were present for med passes where clients were given half doses of medications by staff and were told that the facility did not have the medication available. 2 of 6 residents agreed with the statement the facility was not reordering medications on time. 4 residents were interviewed as part of this visit, 2 self reported memory issues. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. A copy of the report was read and given to the administrator. exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 27-AS-20260218134153

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1,2) · Plan of correction due date: Jul 10, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not followed as evidenced by: In record review, The morphine is a controlled substance and is not being recorded properly on a controlled substances log. In interview, perscribed order(1 per 12 hours) conflicts with the administrators statement (PRN). its distribution as a MAR record is questionable, per interview with S1. This requirement not being followed poses a risk to the health, safety, and personal rights of clients in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: POC Suggestion is do a staff training on how to document MAR records, PRNs, medication Refusals, and controlled substances, Medication distruction record. Training should be with a vendor/hospice/homehealth nurse and not the administrator. 8/10/26

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year/annual required inspection. LPA Lund met with staff and later with Administrator Maria Almendrala and explained the reason for the visit. Census: 6 LPA Lund and Administrator Maria Almendrala toured/inspected the inside and outside of the facility. LPA Lund observed required posters. The facility was found to be clean, safe and sanitary, and in good repair. The facility temperature was comfortable. The hot water temperature measured at 110 degrees F. There are no bodies of water present at the facility. Toxins and sharp tools are stored inaccessible to residents. LPA observed 2- day perishable and 7 – day non-perishable food supply and menu. Fire extinguishers (January 15, 2025), smoke detectors, and carbon monoxide detectors are in compliance. The first Aid kit is complete. Disaster drill were conducted within the last six months. LPA reviewed 3 resident files and 2 staff files (reviewed staff has criminal record clearance). LPA Lund observed centrally stored medications are locked and in compliance. No Deficiencies were observed at this time. Exit interview conducted with Administrator Maria Almendrala and copy of Report Giventhe state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual required inspection visit. LPA Lund met with staff and later with Administrator Maria Almendrala and explained the reason for the visit. Census: 5 LPA Lund and Administrator Maria Almendrala toured/inspected the inside and outside of the facility. LPA Lund observed required posters. The facility was found to be clean, safe and sanitary, and in good repair. The facility temperature was comfortable. The hot water temperature measure at 109 degrees F. There are no bodies of water present at the facility. Toxins and sharp tools are stored inaccessible to residents. LPA observed 2- day perishable and 7 – day non-perishable food supply and menu. Fire extinguishers (July 2024), smoke detectors, and carbon monoxide detectors are in compliance. First Aid kit is complete. Disaster drill conducted within the last six months. LPA reviewed 3 resident files and 2 staff files (reviewed staff has criminal record clearance). LPA Lund observed centrally stored medications are locked. No deficiencies were observed. Exit interview conducted and report left.the state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Facility failed to provide records to responsible party

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with licensee/administrator Maria Almendrala and explained the purpose of the visit. This investigation consisted of record review and interviews. CCLD received a written statement from the reporting party of this complaint, alleging that multiple requests for documentation had been made by representatives of a resident’s (R1) responsible party (R1’s RP) via fax. The complainant provided two letters requesting R1’s complete resident records dating from 1/1/19 to present. The letters were dated 5/2/23 and 6/6/23. [continued on 9099-C] Substantiated The first of these two letters included R1’s advance health care directive, appointing R1’s RP as R1’s attorney-in-fact, along with a written authorization for this facility to release R1’s records to the complainant, which was signed by R1’s RP and dated 4/24/23. The second of these two letters reiterated the request for documents. Both letters were sent via fax. LPA Moleski reviewed R1’s file at the facility and observed a letter, dated 4/27/23, sent to the facility by representatives of R1’s RP. The letter outlined a request for R1’s complete resident records dating from 1/1/19 to present. LPA Moleski reviewed R1’s LIC 601 and observed that R1’s RP was listed as R1’s responsible party. During an interview, Almendrala confirmed that she had received both letters sent by representatives of R1's RP via fax. Almendrala provided copies of the letters to LPA Moleski. Almendrala said that, prior to receiving these faxed letters, she had provided R1’s RP with R1’s admission agreement, and no further documents. Almendrala said she took no further action after receiving the faxed letters. LPA Moleski interviewed a representative of the complainant on 11/17/23. The representative said the complainant no longer needs the documents requested. The department has determined the following as it relates to the allegation that the facility failed to provide records to a responsible party: Based on record review and interview with Almendrala, records were not provided within two days as required. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87468.2(a)(19). An exit interview was held with Almendrala. Appeal rights and a copy of this report were left with Almendrala.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 27-AS-20230706143717

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Nov 22, 2023

22 CCR Section 87468.2(a)(19) – Additional Personal Rights of Residents in Privately Operated Facilities: “To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.” This requirement was not met as evidenced by: Based on record review and interview, the licensee did not provide R1, represented by R1's RP, represented by the complainant, with R1's resident records within two days of receiving a written records request, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Nov 21, 2023

Plan of correction: Licensee agrees to review 22 CCR Sections 87506(c)(1) and 87468.2(a)(19) and write a signed statement acknowledging having done so and asserting that these sections will be complied with in the future. Licensee agrees to send LPA Moleski a copy of this signed statement by the POC due date. Failure to correct this deficiency by the POC due date will result in civil penalties. vincent.moleski@dss.ca.gov