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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005036
Report Date: 01/22/2025
Date Signed: 01/22/2025 10:29:00 AM

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
01/16/2025 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250116102201
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: ZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
01/22/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Nora GardoseTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff are not providing an adequate supply of food.
unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to open an complaint for the above allegations. LPA was greeted by staff and explained the reason for the visit.

LPA Lewis interviewed R1-R3 and S1 regarding the above allegations. Based on interviews with staff and residents and observatiosn by LPA Lewis of the the food supply. The above allegations are SUBSTANTIATED. As a result, the preponderance of evidence standard for this allegation is met, therefore, this allegation is SUBSTANTIATED.

Deficiencies cited see 9099D page per California Code Regulation, TITLE 22.

Exit interview was conducted and a copy of the report and appeal rights given.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20250116102201
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: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2025
Section Cited
CCR
8722(a)
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87224(a) Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5) …

This requirement was not met as evidence by:
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Administrator agrees to review eviction regulations by POC date 01/23/25. Administrator agrees to provide a written statement to LPA via email that states the review of eviction regulations has been completed by POC Date 01/23/25 by end of day 5:00 PM
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Based on interviews, withreporting party and R1-R3 the licensee stated the residents were going to be evected and evicetion is used as way to forse residents to do things. This poses a potential health and safety to residents in care.
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Kesha.lewis@dss.ca.gov
Type A
01/23/2025
Section Cited
CCR
85076(d)(1)
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LPA did not obaserve adequate food supply of non perishable foods.
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Licensee shall submit food receipts for the last 12 months by 01/24/2025 due date.
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Based on LPA observations of the food supply and interviews with residents did not obaserve adequate food supply of non perishable foods. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
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Licensee will go shopping and supply the facility with food and send the reciept and photos of the food in the facility to LPA Lewis by poc date 01/23/2025.
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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2