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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801999
Report Date: 05/24/2021
Date Signed: 05/24/2021 07:15:27 PM

Document Has Been Signed on 05/24/2021 07:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 36DATE:
05/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Rufus ZingkhaiTIME COMPLETED:
12:30 PM
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Licensing Program Analyst(s) (LPAs) Sarangi and Fernandes-Goes conducted an unannounced Required – 1 year. Infection Control inspection to this facility and met with administrator Rufus Zingkhai. There was 36 residents present at the facility.

LPAs arrived at the facility and had our temperatures checked and logged into a log. During facility tour on 5/24/2021 with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on March 20, 2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. There was a sufficient supply of both perishable and non-perishable foods as required by Title 22 Regulations. Food stored in the refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the hallway. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. LPAs observed beds with pans down below filled with Vegetable Oil for bedbugs. LPAs observed bedbugs in the bowl. After review, it was disclosed in May 2020 facility had a complaint regarding bed bugs which was unsubstantiated due to facility having an exterminator coming to the facility. During this visit as per documentation on file provided by administrator Rufus Zingkhai, last exterminator visit occurred on 3/2020. Facility administrator also stated that there is an email showing as proof of last treatment occurring on 10/2020. Facility had no proof of service/receipt. (see pictures, LIC 809-D)

Infection Control:
Facility has submitted a mitigation program plan that was approved on March 01, 2021. Staff before coming into work have temperature checked. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SAINT MICHAEL'S EXTENDED CARE
FACILITY NUMBER: 216801999
VISIT DATE: 05/24/2021
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Facility has PPE supply stored in the Administrator office at the facility. There has been 1 new staff hired since COVID-19. Residents’ medications are stored and locked in the hallway across the Administrator office. Facility has a 30-day supply of medication for clients. Residents are wearing masks inside the facility. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

In addition, LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one on March 10, 2021.

Deficiencies were observed on May 24, 2021 at 09:45 AM, and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given to the Administrator. A copy of this report was signed by the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2021 07:15 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 05/24/2021 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SAINT MICHAEL'S EXTENDED CARE
FACILITY NUMBER: 216801999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during a tour of the facility on May 24, 2021 at 09:45 AM, the licensee did not comply with the section cited above in most of the bedrooms which poses an immediate health, safety or personal rights risk to persons in care. In addition, on 5/2020 Department received a complaint allegation of bed bugs in the facility. Allegation was unsubstantiated due to facility had an exterminator. According to facility records last visti of exterminator was in 3/2020 with a possible visit in 10/2020 .
POC Due Date: 05/25/2021
Plan of Correction
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Licensee to submit a proof of pest control company assessment situation of situation steps taken in addition to guidelines that facility is following by Plan of Correction by 05/25/2021. Facility will use exterminator to rid of the bedbugs and prove that the facility is clear of the bedbugs. Faciliyt will need to be fully clear of bedbugs by June 24, 2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2021


LIC809 (FAS) - (06/04)
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