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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:12:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/04/2022 04:12 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:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Nora GardoseTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual inspection on this date. LPA met with Staff and explained the purpose of the visit.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. During the tour LPA observed expired food in the pantry. Hot water temperature was measured at 119 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present. Fire drill was conducted on 7/21/2022.

LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. All staff today are associated to the facility. During the staff file review LPA observed an expired First aid/CPR card for S1. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Deficiencies were cited during this visit.

Exit interview held and a report given at the conclusion of the visit
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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Document Has Been Signed on 08/04/2022 04:12 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/04/2022 at 01:39 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2022
Section Cited
CCR
80075(f)

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80075(f) Health Related Services. Staff providing care and supervision shall receive first aid training from qualified agencies including but not limited to the American Red Cross.
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Administrator will review staff files to assure all staff are First Aid qualified. Send POC for S1 completion of First Aid to LPA by POC date.
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This area is not met by: LPA reviewed S1's file and observed an expired First Aid/CPR Card
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Type B
08/12/2022
Section Cited
CCR80087(a)

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Food Services (a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients
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Caregiver immediately disposed of the expired food. Administrator will remind staff to check for and dispose of all expired or inappropriate food in the refrigerator on a weekly basis.
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This requirement was not met as evidence by expired can goods in the pantry. This is a potential safety hazard.
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Plan should be sent to LPA by POC date of 8/12/2022
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
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