<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203009
Report Date: 02/15/2023
Date Signed: 02/15/2023 03:09:03 PM

Document Has Been Signed on 02/15/2023 03:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MICHAEL'S RESIDENTIAL HOME CAREFACILITY NUMBER:
397203009
ADMINISTRATOR:OGBUEHI-NZAMBI, VICTORIAFACILITY TYPE:
735
ADDRESS:5125 JETTY DRIVETELEPHONE:
(209) 234-2215
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
02/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH: J. Githua and A. DioufTIME COMPLETED:
03:31 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Johnson arrived at the care facility and met with Staff to conduct a case management visit into an incident report received on 02/10/2023 from Open Door Services.

R1 had a fall due to a seizure at the care home on 2/9/2023 in the evening and was sent to San Joaquin General ER, as a result of the visit R1 received sutures just below the left knee and was sent back home. The facility called the Regional Center and was preparing to send the incident report to all parties, but was contacted by the day program prior the facility notifying the day program. The facility did not notify Licensing by phone or email; because the Administrator thought that she did not have to call the department she thought she just had to send the incident report within seven days.

LPA advised the facility regarding:

80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.(b) upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.(D) Any injury to any client which requires medical treatment. No deficiencies were cited. Advisory given, the seven days requirement has not expired. The event happened on 2/09/23.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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 1