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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 10/28/2025
Date Signed: 10/28/2025 02:09:28 PM

Document Has Been Signed on 10/28/2025 02:09 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 #2FACILITY NUMBER:
397005036
ADMINISTRATOR/
DIRECTOR:		OGBUEHI, VICTORIAFACILITY TYPE:
735
ADDRESS:1152 RIVER CREST COURTTELEPHONE:
(209) 323-5966
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
10/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst LPA Noel Wolf Petersen, arrived unannounced to conduct a annual inspection, LPA met with the staff Nora Gardos and explained the purpose of the visit. Michaels Residential Home Care 2 is a 6 capacity facility, with a current census of 6. San Joaquin Behavioral Health vendors the business. No restricted condtions at this time, one person with diabedes able to self administer insulin.

Physical inspection was conducted, including but not limited to the common area, kitchen, staff room, bathrooms, storage areas, exterior, evacuation route, and client bedrooms. Facility is clean, traffic areas are unobstructed and well lit. There is some damage to the stairs and a chair that is secured with packing tape, LPA asked those to be be repaired.

Kitchen has toxics and medications stored with the locks on but not twisted or pressed into actually locked position. LPA asked toxics and medications to remain locked. Adequate food for 2-days perishable, 7-days non-perishable. 2 clients raised a concern about bland/repetitive food choices. Weekly menu exists and foods available are reflected, nutrient requirements are planned to be met. Fire extinguisher is present, dated 4/23/25, Receipt verifies purchase date.

Bathroom, has some personal hygine items stored unlocked, but 602's don't reflect any diagnosed behaviors with consequences for grooming/bathing. The screen in the upstairs bathrooms has some tears. LPA asked screen to get replaced. Water temperature delivered above 120*F, LPA asked for the water heater to be turned down.

Exterior is clean, Evacuation route gate is out of repair, drags against the ground. LPA asked gate to be rehung or the bottom edge to be shaved.

Continued on c Page
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 #2
FACILITY NUMBER: 397005036
VISIT DATE: 10/28/2025
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Resident bedrooms have the requisite furniture and furnishings. Occupants preferred LPA not to check on the bed encasements.

Record review of Client files, 5 of 6 client files reviewed had TB, recent medical assessments, and signed admission agreements, signed personal rights up-to-date and present. Personal property, Individual needs and services plans, are present and either unfilled out or sparsely filled out. LPA asked those records to be filed out completely. Clients are either in charge of thier own money or use a payee service where cash is not kept by the facility.

Record review of staff files, 2 of 2 staff files reviewed had DOJ/FBI fingerprint clearance and first aid certificates, ongoing training and TB certificates.

Record review of administrator files, facility license, liability insurance, facility sketch, emergency contact, Ombudsman poster, and fire drill records are posted. Infection control plan, Evacuation plan, are not present, Personal rights poster is aged significantly, LPA gave guidance to print off and post a copy of personal rights attached to the admission agreement. LPA asked to be sent a copy of the evacuation plan and infection control plan, and a copy to be left in the facility for the staff. A Posting of the clients doctors was up, LPA asked that emergency contact sheet to be stored locked and not posted as it has client medical information on it.

Interviewed 3 clients. General consensus is everything is alright, a upstairs couch for the tv would be nice. A meeting once a month to bring up house concerns, activity concerns, menu concerns, ect. would be appreciated.

Interviewed 1 staff. Staff is unsure of the plan of where to go in the event of a significant fire where the building is compromised.

Citations issued regarding repairs and unlocked medication on attached D-page. TA's and TV's issued related to other concerns. exit interview conducted, appeal rights provided, a copy of the report was read and given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2025 02:09 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 10/28/2025 at 01:02 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 #2
FACILITY NUMBER: 397005036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2025
Section Cited

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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored:(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met as evidenced by:
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Observation by the LPA of medications storage locker unlocked. This poses a risk to the health, safety, and personal rights of clients in care.
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Type B
11/04/2025
Section Cited

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80087 Buildings 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 was not met as evidenced by:
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Observation by the LPA of the chair, stair, window screen, and evacuation route gate.

This posed a potential risk to the health, safety, and personal rights of clients 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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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