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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310305298
Report Date: 09/05/2024
Date Signed: 11/19/2024 03:02:03 PM

Document Has Been Signed on 11/19/2024 03:02 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/
DIRECTOR:		SEISA, ELDAFACILITY TYPE:
735
ADDRESS:3345 BOWDER LANETELEPHONE:
(530) 823-1609
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 11CENSUS: DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Patricia Chu, Elda SeisaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 9/5/2024 LPA Tryon and LPA Gunby arrived at the facility to conduct an annual visit. LPAs met with Administrator Patricia Chu. The facility currently has 6 residents.

LPAs Gunby, Tryon and Licensee toured facility together to ensure health and safety of residents in care. Areas toured include common areas, resident bedrooms, backyard, and restrooms, kitchen. 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. LPA's observed two (2) fire extinguishers which were recently serviced and are charged.

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

LPA reviewed a total of ftwo (2) residents' files and two (2) staff files.

LPA reviewed the CARE Tool with Administrator.

No citations were issued.

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

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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