216801999-5-14-2025-21-AS-VBEI-DGQM5C-20250516091804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801999
Report Date: 05/14/2025
Date Signed: 05/14/2025 01:08:31 PM

Substantiated

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
03/20/2025 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20250320124909

FACILITY NAME:	SAINT MICHAEL'S EXTENDED CARE		FACILITY NUMBER:	216801999
ADMINISTRATOR:	ZINGKHAI, RUFUS		FACILITY TYPE:	740
ADDRESS:	416 4TH STREET		TELEPHONE:	(415) 453-4600
CITY:	SAN RAFAEL	STATE:	ZIP CODE:	94901
CAPACITY:	44	CENSUS: 37	DATE:	05/14/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Administrator, Rufus Zingkhai		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff is not administering medication per physician's orders
Personal Rights

INVESTIGATION FINDINGS:

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At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for this complaint investigation regarding the above allegations, and met with Administrator, Rufus Zingkhai.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, ”Staff is not administering medication per physician’s orders” and “personal rights.” Complainant alleged that Facility staff was not giving Resident 1 (R1) their Lorazepam medication correctly and that R1 may be overmedicated as a result. Complainant stated that R1’s Lorazepam was a PRN or “as needed” medication but that the facility was giving it to R1 every day.

Continued on LIC9099

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250320124909

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: 05/14/2025

NARRATIVE

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Continued from LIC9099

Review of R1’s centrally stored log and Medication Authorization Record (MAR) stated the following:

· Lorazepam 1MG Tablet; take 1 tablet by mouth once daily as needed 1 hour prior to attending medical appointments

· Centrally Stored Log for R1 showed that Facility received a quantity of 12 tablets.

· Review of R1’s MAR shows that R1 received a dose of Lorazepam from 03/11/25-03/20/25, and on 03/24/25 and 03/25/25

Interview conducted with Marin County Mental Health Supervisor stated that the facility was to monitor and observe R1 for withdrawal and increased anxiety. If observed, facility staff were to contact 911 and ensure R1 received medical attention. Review of facility incident reports showed that on 03/30/2025, R1 was sent to the ER due to increase in anxiety and shortness of breath. Interviews conducted with facility staff confirmed that R1 does not have medical appointments every day and revealed that facility staff did not contact R1’s doctor for clarification on the medication. Based on document review and interviews conducted, these allegations are Substantiated.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights 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: 05/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250320124909

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/15/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on interviews and record review, Licensee did	1 2 3 4 5 6 7	Licensee to submit self certification that training will be conducted for all staff that administer medications by POC due date of 05/15/2025. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Training to be
	8 9 10 11 12 13 14	not comply with the section cited above and did not ensure that Resident 1’s medication was administered per physician’s orders. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	submitted to CCL by POC due date of 05/27/2025.
Type A 05/15/2025 Section Cited CCR 87648.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, residents...shall have... (4) To care, supervision, and services that meet their individual needs...Based on interviews and record review, Licensee did	1 2 3 4 5 6 7	Licensee to submit self certification that training will be conducted for all staff by POC due date of 05/15/2025. Licensee to review personal rights. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Personal Rights Training to be submitted to CCL by POC
	8 9 10 11 12 13 14	not comply with the section cited above. Facility provided medication in excess of the amount prescribed by R1’s psychiatrist. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	due date of CCL by POC due date of 05/27/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

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