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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:17:59 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/07/2023 12:17 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:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Narcisa WooleyTIME COMPLETED:
12:45 PM
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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. During the tour LPA observed medication unlocked in the refrigerator and the facility poster missing for the Ombudsman's office and the Licensing "See Something Say Something." (Advisory given)

LPA observed sufficient seven day non-perishable and two day perishable food supplies. 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 7/21/2023.

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 resident service plans for 5 of 5 reviewed. 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: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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 08/07/2023 12:17 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/07/2023 at 11:51 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
, 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: 08/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2023
Section Cited
CCR
80075k1

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80075(k)(1) Health Related Services. Medication shall be kept in a safe and locked place that is not accessible to persons other than employees...
This requirement is not met as evidenced by:
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The licensee shall immediately lock/secure medications. The licensee shall conduct a staff in-service pertaining to medication storage (topic, instructor, date, time, names, signatures) and provide to LPA via email by 8/8/23
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Based on observation, the licensee failed to keep medications in a safe and locked place. LPA observed unlocked resident's medication in the kitchen refrigerator. This poses an immediate 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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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