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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 09/16/2025
Date Signed: 09/24/2025 09:15:00 AM

Document Has Been Signed on 09/24/2025 09:15 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MICHAEL'S RESIDENTIAL HOME CARE, INC.FACILITY NUMBER:
397005036
ADMINISTRATOR/
DIRECTOR:		OGBUEHI, VICTORIAFACILITY TYPE:
735
ADDRESS:1152 RIVER CREST COURTTELEPHONE:
(209) 323-5966
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
09/16/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Victoria Ogbueui- NzambiTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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The Sacramento South Regional Office held an office meeting via Microsoft teams on 09/16/25 at 10:30 AM. The purpose of the meeting was to discuss Solvency and Trust Audit Report Findings. Present in today's meeting were Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Kesha Lewis LPA Noel Wolf Peterson, Gereral Auditor (GM) Benjamin Banahene, and Licensee/Administrator Victoria Ogbueui- Nzambi, Kathryn Thomas Ombudsman, Danielle Wiseman Behavioral Health Services and Katina Richison Valley Mountain Regional.
Topics of Discussion:
Solvency Audit Report Findings - Based on information received and reviewed, it appears that the licensee has positive net income for both facilities. However, supporting documents for major expenses (payroll records) were not provided, and the auditor cannot verify if the reported expense was adequate.
The mortgage statements provided by the licensee show that each of the facilities’ mortgage is current and paid, which demonstrates that the licensee has control over both facilities. The facilities’ utility statements provided showed that the licensee did not make or made partial payments for some months. The bank statements show the licensee did not have sufficient cash reserve for some months. Additionally, the licensee did not provide workers’ compensation insurance.
Improvements are needed to ensure the licensee is solvent and in compliance.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MICHAEL'S RESIDENTIAL HOME CARE, INC.
FACILITY NUMBER: 397005036
VISIT DATE: 09/16/2025
NARRATIVE
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Licensee will do the following:
• Financial Monitoring documents to submit for review should include April, May & June 2025 LIC 401 with supporting documents, April, May & June 2025 utility statements, bank statements, and LIC 403 with supporting documents, as well as obtain and maintain General Liability Insurance and Workers Compensation Insurance for the two facilities. An updated LIC 500 for each facility and surety bonds for each facility.
Other information and documentation to be requested, as needed by September 23th, 2025.
Licensee to provide to the department by the 3rd week following each quarterly visit, provide to the department an, income statement (LIC 401 or equivalent) with support, for the last month in the quarter and Bank statements (savings and checking accounts) and Utility vendor’s billings for each month of the previous quarter.
Licensee to provide the department with a statement regarding Licensee Business Cash Reserves by September 23th, 2025.

The Regional Office will do the following:
> Continue Quarterly Financial Monitoring for a period of six (6) Months (to March 11, 2026) or until the facility is in compliance.
> RO to determine quarterly status after two quarterly periods
> Continue to collaborate with Licensee as needed

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies are being cited on today's visit. An exit interview was held, and a copy of the report and appeal rights were provided via e-mail. Licensee to review, sign, and return signed copy to LPA by COB 09/17/2025.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/24/2025 09:15 AM - It Cannot Be Edited


Created By: Kesha Lewis On 09/16/2025 at 08:37 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MICHAEL'S RESIDENTIAL HOME CARE, INC.
FACILITY NUMBER: 397005036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2025
Section Cited
CCR
87405(d)(1)

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87405 Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
(d) The administrator shall have the qualifications specified in Sections
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Licensee will review regulation and submit a statment of understanding to the department by 9/17/2025.
Noel.Wolfpetersen@dss.ca.gov
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This requirement is not met as evidenced was not able to provide documatation to the department that is required. Information was not known regaring the title 22 regulations. This poses a potential health,and saftey risk to residents in care.
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Type A
09/17/2025
Section Cited
CCR87755(c)

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87755 Inspection Authority of the Licensing Agency

(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).
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Licensee will provide a plan to the department to ensusure Inspection Authority for the Licensing Agency by COB 9/17/2025.
Noel.Wolfpetersen@dss.ca.gov
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Based on LPA observations, and interview with the licensee did not comply with the section cited above as the licensee did not provide needed paperwork to the audits section when requested. Which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Kesha Lewis
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2025 09:15 AM - It Cannot Be Edited


Created By: Kesha Lewis On 09/16/2025 at 09:24 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MICHAEL'S RESIDENTIAL HOME CARE, INC.
FACILITY NUMBER: 397005036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
87213

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87213 - Finance; RecordsThe licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency...
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Licensee agrees to email LPA a written financial record of operating expenses monthly for the next three months begining 9/1/2025.

Licensee agrees to email POC by 9/26/2025
Noel.Wolfpetersen@dss.ca.gov
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This requirement is not met as evidenced by:Interviews and file reviews, the licensee did not ensure to have the sufficient resources to meet operating costs for utilities in December of 2024. This posed a potential health and safety risk to residents in care.

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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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Kesha Lewis
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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