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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801999
Report Date: 04/17/2024
Date Signed: 04/17/2024 02:45:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20231228160617
FACILITY NAME:SAINT MICHAEL'S EXTENDED CAREFACILITY NUMBER:
216801999
ADMINISTRATOR:ZINGKHAI, RUFUSFACILITY TYPE:
740
ADDRESS:416 4TH STREETTELEPHONE:
(415) 453-4600
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:44CENSUS: 33DATE:
04/17/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Rufus ZingkhaiTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not address resident behavior resulting in a resident's injury
Staff did not seek medical attention for resident in a timely manner
Staff did not accord resident dignity in their relationship with staff or other persons
Staff did not follow resident's special accommodations
INVESTIGATION FINDINGS:
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Staff Member, Sheila Manansala. Administrator, Rufus Zingkhai, arrived during visit at approximately 10:00AM.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff did not address resident behavior resulting in a resident's injury, Staff did not seek medical attention for resident in a timely manner, Staff did not accord resident dignity in their relationship with staff or other persons, and Staff did not follow resident's special accommodations.” The Department reviewed facility records, facility logs, and conducted interviews with involved parties and facility staff.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
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 3
Control Number 21-AS-20231228160617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAINT MICHAEL'S EXTENDED CARE
FACILITY NUMBER: 216801999
VISIT DATE: 04/17/2024
NARRATIVE
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Continued from LIC9099

Reporting Party stated that there was a physical confrontation between Resident 1 (R1) and Resident 2 (R2) and facility did not address R2’s behaviors resulting in R1 having their hand injured. LPA conducted interviews with involved parties and received inconsistent statements. Some interviews conducted stated the confrontation happened while others denied it occurred. LPA conducted staff interviews. Per staff interviews, LPA was informed that R1 and R2 used to be roommates, but the facility separated R1 and R2 into different rooms because they would argue with each other. Since R1 and R2 were separated, staff have not observed the residents interacting much. Review of R2’s Physician Report dated 02/17/2022 stated they did not have a history of aggressive behavior. LPA did not find any documentation on how facility staff are to address resident behaviors.

Reporting Party stated that facility staff speak to R1 in an annoyed way and do not clean R1’s room or take out their trash. Per staff interviews, staff have not observed or seen residents being spoken to in a rude or demeaning way. Staff interviews stated that R1 would refuse to have their room cleaned and preferred to leave their trash bags outside of their room for staff to pick up. Staff interviews also stated R1 has been observed to have verbal altercations with other residents but were unable to recall specific details. During visit conducted on 04/03/2024, LPA observed that R1’s room was clean, had the trash taken out, and did not have any strong odors.

Reporting Party stated that facility staff did not seek medical attention for R1 in a timely manner. Facility documents dated 12/06/2023, showed that facility staff were informed by R1 that their hand was slammed by their bathroom door. Facility staff assessed R1’s hand and did not observe bruising or swelling. Review of R1’s file showed a signed agreement dated 04/28/2022 between R1 and the facility. The agreement stated that R1 did not authorize facility staff to communicate with their Primary Care Physician regarding any medical condition. Staff interviews conducted corroborated this agreement, and stated R1 would verbally tell staff when they had appointments scheduled. Facility staff interviews also stated that they provided transportation to and from these medical appointments but would sit in the waiting room. R1’s Physician Report dated 02/27/2023, showed that R1 can leave the facility unassisted and can communicate their needs. Review of R1’s Care Plan dated 02/28/2023, stated that R1 attends their medical appointments independently. Facility documents showed that R1 had a Primary Care Physician appointment scheduled for 12/15/2023 and 12/19/2023. Per staff interviews, facility staff took R1 to their appointment on 12/19/2023 and provided ice when R1 requested it, per doctor’s instructions. LPA conducted interviews with involved parties and was informed that R1 did not tell facility staff their hand hurt.

Reporting Party stated that staff did not follow R1’s special accommodations. Review of R1’s Physician’s Report dated 02/27/2023, stated that R1 had environmental allergies and chemical sensitivities. Review of R1’s file showed a signed agreement dated 08/26/2022 between R1 and the facility.

Continued on LIC9099C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20231228160617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAINT MICHAEL'S EXTENDED CARE
FACILITY NUMBER: 216801999
VISIT DATE: 04/17/2024
NARRATIVE
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Continued from LIC9099C

The agreement stated the facility can use cleaning products such as diluted Clorox and Bon Ami to clean R1’s bedroom and bathroom, and that the facility cleaning cart would be placed five feet from R1’s room. Staff interviews conducted corroborated this agreement. During visit conducted on 04/03/2023, LPA observed that R1’s room was clean and did not have any strong smelling odors.

Based on inconsistent statements and lack of corroborating evidence, LPA is unable to determine if violations occurred, therefore these allegations are Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.



Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3