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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203009
Report Date: 12/02/2025
Date Signed: 12/23/2025 08:10:17 AM

Document Has Been Signed on 12/23/2025 08:10 AM - 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 CAREFACILITY NUMBER:
397203009
ADMINISTRATOR/
DIRECTOR:		OGBUEHI-NZAMBI, VICTORIAFACILITY TYPE:
735
ADDRESS:5125 JETTY DRIVETELEPHONE:
(209) 234-2215
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
12/02/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Victoria Ogbuehu-NzambiTIME VISIT/
INSPECTION COMPLETED:
01:21 PM
NARRATIVE
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On 12/2/25 at 1:30pm Licensing Program Analyst, LPA, Noel Wolf Petersen the arrived unannounced to conduct a case management related to a audit by the department. LPA met with the adminstrator Victoria Ogbuehi-Nazambi and explained the purpose of the visit.

A summary of ongoing reports collected by the audit concludes that the facility failed to implement a plan in response to persistant, high, unpaid balances carried on the facilities utility bills. The department’s review of the 2nd quarter of 2025 Financial monitoring records supports the assertion that a requirement by law to maintain financial solvency was not met by the facility. The review of the operating statements and the supporting documents show that the two facilities show positive net incomes for each of the three months of April, May and June 2025. The mortgage statements provided by the licensee show that each of the two facilities’ mortgage is current and paid, which demonstrates that the licensee has control over both facilities. However, the review of the utility records from the third-party vendors show that the licensee missed, did not make payments for some months and at times carried high unpaid balances. Improvements are needed to ensure the licensee is solvent and in compliance. Therefore, upon review of all the records provided, it appears the two facilities may not have an adequate financial plan, as required by law.

Additionally, it was learned through record review that required Workers Comp insurance was not purchased for the facility's workers. Documentation of the workers comp insurance status and other elements required to be submitted to the department as part of the departments audit were not presented in a timely or substantially complete manner. The departments's review of the 2nd quarter of 2025 Financial monitoring records supports the assertion that a requirement by law to maintain financial solvency was not met by the facility.

Citations are issued, and appeal rights were provided. An exit interview was conducted and 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: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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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Document Has Been Signed on 12/23/2025 08:10 AM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 12/02/2025 at 01:24 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
FACILITY NUMBER: 397203009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2025
Section Cited
CCR
80063(a)(1)

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80063(a)(1) Accountability (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. (1) If the licensee is a corporation or an association, the governing body shall be active and functioning in order to ensure such accountability.
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The Financial Monitoring (FM) review to be continued for 3Q Y2025. The due date to submit the FM records is
12/10/2025 (for 3Q2025 July, August, September, monitoring period). FM
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This requirement was not met as evidenced by:

Failing to implement a plan to address shortfalls in payments to utilities in the months of April, May, and July 2025. Which poses a risk to health, safety and personal rights to the clients in care.
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documents to submit for review should
include July, August & September 2025 LIC 401 with supporting documents, July, August & September 2025 utility
statements, bank statements, and LIC 403 with supporting documents,
Type B
12/03/2025
Section Cited
HSC80044(c)(1)

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80044(c)(1) Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements specified in Sections 80066(c) and 80070(d). (1) The licensee shall ensure that provisions are made for the examination of all records relating to the operation of the facility.
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No POC, LPA sent a copy of the workers comp, to be forwarded to the Financial Monitoring Auditor.
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This requirement was not met as evidenced by:
Failing to provide workers comp insurance to the department when requested for review. Which 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: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2025 08:10 AM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 12/02/2025 at 01:32 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
FACILITY NUMBER: 397203009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2025
Section Cited
HSC
80064(a)(3)

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80064(a)(3) Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.
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No POC required, workers comp was provided to the LPA during the visit.
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This requirement was not met as evidenced by:
Failing to purchase required workers comp insurance during Q2 of 2025. This poses 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: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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