<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310305298
Report Date: 08/21/2023
Date Signed: 08/21/2023 03:49:13 PM

Document Has Been Signed on 08/21/2023 03:49 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ST. MICHAEL RESIDENTIAL CARE HOMEFACILITY NUMBER:
310305298
ADMINISTRATOR:SEISA, ELDAFACILITY TYPE:
735
ADDRESS:3345 BOWDER LANETELEPHONE:
(530) 823-1609
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 11CENSUS: 8DATE:
08/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Adminstrator- Patrica ChuTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/21/2023, Licensing Program Analysts (LPA's) Jaynae Boyles and John Tryon arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPAs met with Facility Administrator, Patrica Chu and explained the purpose of the visit.

LPAs Boyles, Tryon and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms,backyard, and common restrooms. LPA's observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured at 118 F. LPA's observed two (2) fire extinguishers which are in need of servicing and the Administrator will be scheduling an appointment to ensure they are serviced.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) residents' files and four (4) staff files.

Several topics were discussed.

The following citations are cited as per Title 22 Regulations. Appeal right were given.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/21/2023 03:49 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 08/21/2023 at 03:13 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST. MICHAEL RESIDENTIAL CARE HOME
FACILITY NUMBER: 310305298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)


This requirement is not met as evidenced by: Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
Fire extinguishers in main hallway and kitchen, have expired tags, posing and immediate health and safety risk.
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. The requirement was not met as evidenced by: Two fire extinguishers in the facility were charged, but had not been checked since November 2021.
POC Due Date: 08/28/2023
Plan of Correction
1
2
3
4
The Administrator will have the fire extinguisher serviced and maintain the service.
Type B
Section Cited
CCR
80075(f)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement was not met as evidenced by: Staff S1 and S2 have expired First Aid certification; certification expired May 2023.
POC Due Date: 09/21/2023
Plan of Correction
1
2
3
4
The administrator and care staff will obtain their first aid certification.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2