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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 01/27/2022
Date Signed: 02/16/2022 12:05:30 PM

Document Has Been Signed on 02/16/2022 12:05 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MICHAEL'S RESIDENTIAL HOME CARE, INC.FACILITY NUMBER:
397005036
ADMINISTRATOR:OGBUEHI, VICTORIAFACILITY TYPE:
735
ADDRESS:1152 RIVER CREST COURTTELEPHONE:
(209) 323-5966
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
01/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Amelie Diouf TIME COMPLETED:
02:30 PM
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LPA Johnson arrived at the care facility and met with Amelie to conduct a case management visit into an incident report received on 1/21/2022.

R1 was sent out to mental health after attempting to harm himself. The facility was told by the police department that R1's file had to go with him to the ER. R1 was admitted to St. Joseph's behavior hospital after being transferred from San Joaquin General, were R1's file was sent along with R1. R1's file is missing and neither hospital has produced the file to date. R1's file is missing.

LPA informed the facility that they will need to re-establish a file for R1 and also to develop an emergency file that will be sent with any resident while in need of emergency services.

No deficiencies were cited.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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