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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801999
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:38:33 PM

Document Has Been Signed on 06/14/2023 03:38 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 31DATE:
06/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff Members, Francisco Preciado and Giov Alipio TIME COMPLETED:
03:50 PM
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At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Continuation Visit and was greeted by Staff Members Francisco Preciado and Giov Alipio. Upon arrival, LPA was informed that there were currently 31 Residents in care, and 6 staff members on site. Administrator, Rufus Zingkhai, arrived later during visit at approximately 1:30PM.

At approximately 12:45PM, LPA reviewed a sample size of 4 Resident files, and 3 staff files. Client and Staff files were all found to be well organized, thorough and contained the required documentation. Administrator's Certificate (6053315740) was current with an expiration date of 08/15/2023. At approximately 2:00PM, LPA reviewed a sample size of 4 Resident medication records. Medication was observed to be centrally stored and secure. At approximately 2:40PM, LPA conducted staff and resident interviews.

LPA is requesting the following documents to update the facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Current Administrator's Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of Friday, July 14, 2023.

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: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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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