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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 08/14/2023
Date Signed: 08/14/2023 11:08:21 AM

Document Has Been Signed on 08/14/2023 11:08 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
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:
08/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:TIME COMPLETED:
11:15 AM
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LPA Albert Johnson arrived at the care home today and met with caregiver to conduct a plan of correction (POC) visit in relation to a citation issued during an annual required inspection on 8/07/2023.

LPA toured the facility and checked food supply. Based upon this inspection, the LPA observed the following:

*Deficiency cited under Title 22 Regulation have been cleared. Licensee complied with the terms of the POC by POC due date.

Deficiencies cleared.

POC letter printed.

Exit interview.

Plan of Correction:
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		Corrections:
Cleared By Visit		Clearance Date:
08/14/2023
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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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