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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607902
Report Date: 01/21/2022
Date Signed: 01/21/2022 01:57:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. MICHAELS HOME FOR THE ELDERLYFACILITY NUMBER:
197607902
ADMINISTRATOR:JAMES MCGEEFACILITY TYPE:
740
ADDRESS:1506 S. CANDISH AVENUETELEPHONE:
(951) 532-4644
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 6DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Barb Boiston, House ManagerTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with House Manager, Barb Boiston and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files.

All resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Resident bathrooms were toured. Bathrooms have the required grabs bars and non-skid mat. The hot water was 108.9 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and working properly. There is additional food in the refrigerator located in the garage. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area.

LPA reviewed 6 resident files to confirm emergency contact is updated and residents have health screenings and vaccinations. LPA also confirmed staff working have fingerprint clearances. LPA reviewed 6 residents' medications. Medications are documented and stored properly.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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