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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376401726
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:08:11 PM

Document Has Been Signed on 05/30/2024 03:08 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MICHAELLE HOUSEFACILITY NUMBER:
376401726
ADMINISTRATOR/
DIRECTOR:		PAUL KEARSCHNERFACILITY TYPE:
736
ADDRESS:687 RIVIERA COURTTELEPHONE:
(760) 758-9165
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 12CENSUS: 5DATE:
05/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:08 AM
MET WITH:ADMINISTRATOR, DANNI HICKEYTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On May 30, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct a Case Management visit and met with the Administrator, Danni Hickey.

LPA Mixson toured the facility along with the Administrator and no deficiencies were observed. On May 22, 2024, the Department received information stating that a resident was not following the program and was given a three-day eviction notice. LPA Mixson requested (R1's) file, along with the facility's eviction procedures, and the current location and forwarding contact information for the listed resident.

Based on the information obtained there are no immediate threats to the health, safety, and/or welfare of the residents in care, However, deficiencies will be cited for illegal eviction, Section 87868.1 (c) sub section 1. Resident Eviction Procedures.



The facility did not submit a written or verbal notice to licensing requesting the three-day notice of a resident in care. The facility did not submit the required documentation for the approval of the eviction and maintain the approval in the resident file. The facility did not assist the resident with relocation, and this pose a potential health and safety risk to resident.


An exit interview was conducted, and a copy of this report, along with the Appeals Procedures for applicants and Licensees, 809-D, and LIC 811. was provided to the Administrator, Danni Hickey.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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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Document Has Been Signed on 05/30/2024 03:08 PM - It Cannot Be Edited


Created By: Venus Mixson On 05/30/2024 at 09:25 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MICHAELLE HOUSE
FACILITY NUMBER: 376401726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2024
Section Cited
CCR
87868.1(c)

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87868.1 Resident Eviction (a) The licensee shall be permitted to evict a resident with 30 days written notice for any of the following reasons:
(1) Nonpayment of the basic rate for the provision of basic services within ten days of the due date.
(2) Failure of the resident to comply with the provisions of the Admission Agreement.
(b) The licensee shall evict the resident if he/she refuses to relocate within thirty (30) days of a written notice under the following circumstances:
(1) Modifications to the resident's Individual Services Plan specified in Section 87896 indicate that the resident's needs can no longer be met by the facility.
(A) Under these circumstances, the resident shall be given an opportunity to voluntarily relocate.
(B) The facility shall assist the resident to relocate, if needed.
(2) The resident's needs can no longer be met in the facility and his/her continued placement is inappropriate due to a change in the facility license or facility program.
(c) The licensee shall be permitted to evict a resident with three days prior written notice if the resident has engaged in behavior which poses a threat to himself/herself, other residents, and/or the facility personnel.
(1) Prior to an eviction, the following requirements shall be met:
(A) The Individual Services Team has submitted written approval to the licensee which concurs with the decision to evict the resident.
(B) The licensee has received prior written and/or documented telephone approval for the notice of eviction from the Department.
(C) The Department shall approve or deny the request within two working days of receipt.Based on information obtained, from record reviews, interviews, observations this was not met ...
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The Facility Administrator stated that the Individual Service Team will receive training on the procedures and regulation as outlined in 87868.1(c) of the Regulaitons and that the full regulations are followed, to include that the Department shall approve or deny the request within two working days of receipt.
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as evidence by a resident (R1) being illegally evected prior to the approval or denial of the request by the Department. This pose a potential health and safety risk to resident.
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Venus Mixson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MICHAELLE HOUSE
FACILITY NUMBER: 376401726
VISIT DATE: 05/30/2024
NARRATIVE
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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
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