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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005036
Report Date: 10/29/2024
Date Signed: 10/29/2024 05:16:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20241001103459
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: 6DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Victoria OgbuehiTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility has bed bugs
Facility did not report bed bugs to CCLD
INVESTIGATION FINDINGS:
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LPA Jensen arrived at facility to continue an investigation in to the above listed allegations. LPA Jensen met with Licensee Victoria Ogbuehi and explained the purppose of today's visit.

Allegation 1: LPA Jensen toured the facility and observed evidence of a bed bug infestation in the pillows and mattresses. LPA Jensen interviewed 3 clients who confirmed there are currently bed bugs. This complaint investigation was opened by the Department on 10/9/24. The Licensee states that the facility has attempted to eridcate the infestation with over the counter products but has been unsuccessful. The Licensee has entered in to a contract with a pest control service that is scheduled to come out 10/31/24. Based on LPA Jensen's observations the allegation of facility has bed bugs is SUBSTANTIATED. While the facility did make attempts to treat the infestation, additional actions could have been taken prior to today's date. A finding of SUBSTANTIATED means that the preponderance of evidence standard has been met.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20241001103459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Allegation 2: Facility did not report bed bugs to CCLD
The Licensee confirmed that an incident report (LIC 624) for the bed bug infestation was not sent to the Department therefore the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations. Failure to correct deficiencies may lead to the assessment of civil penalties.

An exit interview was conducted and a copy of this report was provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241001103459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2024
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds
The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by:
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The Licensee has contracted with a pest control service and will email documentation from the pest control service showing the facility is free of bed bugs by the POC due date.
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Based on LPA Jensen's observation of bed bug infestation in mattress and pillows. This poses a potential risk to the health safety and personal rights of residents in care.
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Type B
11/27/2024
Section Cited
CCR
80061(b)(1)(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.
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Based on the Licensee's own admission, a bed bug infestation 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3