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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 10/29/2024
Date Signed: 10/29/2024 05:03:17 PM

Document Has Been Signed on 10/29/2024 05:03 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
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:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:OGBUEHI, VICTORIATIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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LPA Jensen arrived at facility unannounced at approximately 10:15am to conduct a required 1 year annual inspection. LPA Jensen met with a care provider and explained the purpose of today's visit. The care provider was wearing a winter jacket inside the facility. LPA Jensen checked the thermostat which was at 67 degrees Fahrenheit. LPA Jensen requested the care provider turn on the heat and was advised the heating and AC are currently being fixed. The care provider called the Licensee and LPA Jensen met with Victoria Ogbuehi. LPA Jensen explained the purpose of the visit to the Licensee.

LPA requested 6 of 6 resident files and 2 of 2 staff files. The Licensee explained that there are only 3 resident files in the facility and no staff files. 2 staff files were brought later during the visit. LPA is unable to determine if staff and resident files are complete as files were unable for review. LPA Jensen observed 2 residents with personal and incidental fund accounting sheets. When LPA Jensen asked to review the P&I funds she was advised the facility does not manage P&I funds.

LPA Jensen toured the facility, walls and light switch plates were smudged and discolored. Mold was observed in the upstairs bathroom ceiling. Mattresses were observed with holes in them and torn and disintegrating plastic mattress covers. Evidence of bed bug infestation was observed on pillows and mattresses. The bed bugs are being cited under compliant # 27-AS-20241001103459. Ants were observed outside of the staff bedroom. Dead insects were observed against walls behind couches. The facility did not have a 2 day supply of perishable food or a 7 day supply of non-perishable food. During the course of this visit additional groceries were brought in to the facility. A client meeting was held and all residents that participated stated what grocery items they would like to have. Water temperature in the ground level bathroom was in excess of 120 degrees. Technical assistance was provided on personal rights.

Continued on LIC 809C...
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 10/29/2024
NARRATIVE
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The carbon monoxide detector was tested and found to be in good working order. Medications, knives and toxins were observed to be locked and inaccessible to residents in care. The facility had adequate furnishings and adequate lighting. The grounds were toured and all paths were free of obstruction. The landscaping was observed to be maintained. There is sufficient outdoor space for activities. 4 of 6 clients were interviewed.

During the course of this visit the Licensee took the following actions to correct deficiencies:
-Groceries were ordered
-A heating and air conditioning repair contractor came to the property and assessed the issue with the Licensee authorizing the repair in the presence of the LPA
-The Licensee agreed to get portable heaters on this day to maintain warmth for the clients
-The Licensee contacted a contractor to address the mold who agreed to come the facility tomorrow

Deficiencies are being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.


SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2024 05:03 PM - It Cannot Be Edited


Created By: Maja Jensen On 10/29/2024 at 04:34 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
, 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: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of mold in the bathroom, observation of damaged mattresses and inoperable heating and AC system which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee will send receipts for AC/heat repair, mold mitigation and new mattresses by email to LPA by POC due date.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of insufficient food in the refrigerator and pantrywhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Groceries for over $200 was brought to the facility in the presence of the LPA. No further plan of correction is required.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


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