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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310305298
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:19:13 PM

Document Has Been Signed on 12/27/2023 03:19 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:
12/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Elda Seisa, Licensee and Patricia Chu, AdministratorTIME COMPLETED:
03:30 PM
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On 12/27/2023 LPA Tryon visited the home to do a case management. LPA was visiting to look into the death of a resident in November. The resident had not been eating since the beginning of COVID. The doctor had prescribed Ensure, which he had been using over the past 2 years. He has been seen regularly by his doctor, was taking his medication, and had been doing okay.
On 11/8/23 he was not feeling well, was restless, and the home called to get a doctor appointment at UC Davis Medical Office for him. He was seen by the doctor, x-rays were done and the doctor prescribed an antibiotic, for general infections such as UTI or pneumonia, and the resident had taken one dose around 5:30 p.m. Staff had checked on him several times, and found him non-responsive at 9:00 p.m. Staff called 911 and attempted CPR and emergency personnel responded within a few minutes, but he was already deceased. Placer County Sheriff did respond, and then resident was taken for autopsy. The family has told the licensee that the resident had pneumonia; but the doctor had not told this to the home.

LPA has requested copies of Medical Records, IPP, care notes, etc. The home agreed to scan and email files to LPA.

At this time it appears that the home had been following up with ongoing medical care for the resident, following doctor orders, etc. It had been noticed that the resident was acting a little differently a day before, and the home had taken him for a doctor appointment, he had been prescribed an antibiotic, and the home had followed the doctor order. When the resident was found the staff called 911 and attempted CPR as per 911 direction. It appears the home acted appropriately.

LPA will forward information to LPM for review and any follow-up.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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