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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 01/22/2025
Date Signed: 01/22/2025 11:39:42 AM

Document Has Been Signed on 01/22/2025 11:39 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:
01/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nora GardoseTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to open a complaint and during the visit learned of another indent. resulting in this a case management.

LPA Lewis came learned that R4 had fallen and been sent to the hospital on 01/19/2025. LPA Lewis contacted the department to try and verify that the indent had been reported but no report could be found. LPA Lewis interviewed residents and and staff that confirmed this had occurred. see 812's from complaint visit.



Deficiencies cited see 809D page per California Code Regulation, TITLE 22.

Exit interview was conducted and a copy of the report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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Document Has Been Signed on 01/22/2025 11:39 AM - It Cannot Be Edited


Created By: Kesha Lewis On 01/22/2025 at 09:51 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
, 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: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2025
Section Cited
CCR
80061(1)(b)(E)

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 a written report ... shall be submitted to the licensing agency within seven days following the occurrence of such event...Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
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The Licensee agrees to email an attestation that this regulation has been read, understood and will be followed.
Kesha.Lewis@dss.ca.gov
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Based on the LPA verifying the eletronic files via the department, there was no report of R4 fallingand being sent to the hospital was was not reported to licensing. This poses a potential risk to the health, safety and personal rights of 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:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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