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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310305298
Report Date: 03/29/2024
Date Signed: 03/29/2024 04:08:21 PM


Document Has Been Signed on 03/29/2024 04:08 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: 7DATE:
03/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Patricia ChuTIME COMPLETED:
04:30 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 3/29/2024 LPA Tryon visited the facility to follow up with issues on a Facility Action Report issued by Alta California Regional Center on 3/11/2024. LPA met with Patricia Chu and Elda Seisa. The following issues were found to be Substantial Inadequacies by ACRC.
The following areas were noted and correspond to Title 22 regulation violations:

1. Personnel Requirements 80065/80066: Staff Nancy Church had no health screening.

2 Administrator Qualifications 85064: Elda Seisa was listed as Administrator, but her Admin. Certificate has expired.

3. Client violations Discrepancy found in P&I ledgers, no signatures on ledgers, missing receipts.

4. Physical Plant/resident rights: client's room observed with doorknob that locked from outside of the room

5. Medications: Errors in documentation.

The following deficiencies were cited as per Title 22 Regulations and the Health and safety Code.

Exit interview conducted, Appeal Rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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 4


Document Has Been Signed on 03/29/2024 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 310305298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
CCR
80065(g)(1)

1
2
3
4
5
6
7
g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
(1) Except as specified in (3) below, good physical health shall be verified by a
1
2
3
4
5
6
7
Licensee will ensure that all staff have had a health screening and TB test as per regulation. S1 will obtain a physical and report will be submitted to CCL by 4/30/24.
8
9
10
11
12
13
14
health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This was not met as evidenced by: Through documentation review it was found that S1 did not have a health screen.
8
9
10
11
12
13
14
Type B
04/30/2024
Section Cited
CCR85064(b)

1
2
3
4
5
6
7
b) All adult residential facilities shall have a certified administrator.
The requirement was not met as evidenced by: through review of records it was found that the designated Admin, Elda Seisa had an expired Admin. Certificate: and the facility had not notified CCL that Custodio Seisa
1
2
3
4
5
6
7
Licensee will ensure that there is an administrator with a current Admin. Certificate appointed as Administator of the facility; and will notify CCL and Regional Center of the current administrator.
Notice of current Administrator will be forwarded to CCL by 4/30/2024.
8
9
10
11
12
13
14
was appointed as the current Administrator covering the facility.
8
9
10
11
12
13
14
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 03/29/2024 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 310305298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2024
Section Cited
CCR
80075(K)(7)

1
2
3
4
5
6
7
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name,
1
2
3
4
5
6
7
The facility will ensure that Centrally Stored Medication Records are maintained regularly and up to date.
Administrators will complete medication training and submit proof to CCL.
8
9
10
11
12
13
14
strength and quantity. (D The date filled.(E) The prescription number and the name of the issuing pharmacy. (F)Expiration date. (G) Number of refills(H)Instructions, if any, regarding control and custody of the med . This is not met as evidenced by: through observation it was found CSMDR not up to date.
8
9
10
11
12
13
14
Type B
04/30/2024
Section Cited
CCR80026(h)

1
2
3
4
5
6
7
Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care
This was not met as evidenced by: through review of records it was found that receipts were missing and no signatures for cash.
1
2
3
4
5
6
7
The facility will keep ongoing and complete records of resident cash resources. Licensee will complete a P&I training and submit documentation to CCL,

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 03/29/2024 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 310305298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2024
Section Cited
CCR
80072(a)(7)

1
2
3
4
5
6
7
Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
Not to be locked in any room, building, or facility premises by day or night.
This was not met as evidenced by: the facility had installed a bedroom doorknow
1
2
3
4
5
6
7
The facility will not install any locks on the outside of bedroom doors as this could be a safety hazard as well as a clients right violation. The home immedidately removed the doorknob and replaced it with the locking button on the inside of the room for safety and client's rights. POC Complete.
8
9
10
11
12
13
14
on the door backwards after repainting, causing the lock to be on the outside, so that someone could inadvertently get locked in.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4