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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801999
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:29:06 PM

Document Has Been Signed on 04/03/2024 04:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAINT MICHAEL'S EXTENDED CAREFACILITY NUMBER:
216801999
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		ZINGKHAI, RUFUSFACILITY TYPE:
740
ADDRESS:416 4TH STREETTELEPHONE:
(415) 453-4600
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 44CENSUS: 34DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Rufus Zingkhai, Facility Administrator and Giov Alipio, Medical Technician and Designated Representative TIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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At approximately 3:00PM, Licensing Program Analysts (LPAs) Felias and Florio arrived unannounced to conduct a required annual visit. LPAs were greeted by Francisco Preciado, Medical Technician. LPAs were informed that Giov Alipio, Medical Technician and Designated Representative would tour the facility with LPAs to complete the inspection.

LPAs conducted a physical plant walk-through and inspection. LPAs observed the following: The facility was found to be clean with all exits free from obstruction. Facility had emergency lighting. Facility is a two story building with a census of 34 residents with a capacity for 44 residents. LPAs observed required postings including the CCL Complaint Poster. Mattress pads were in place or available for client use. Hot water temperatures for 4 out of 5 sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. LPAs observed one sink without functioning hot water and tempeurature was unable to be tested (See Technical Advisory, LIC9102, Regulation 87303(e)(6)). Facility's fire extinguishers were last inspected March 7, 2024.

LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation) discussed and provided to Designated Representative. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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