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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203009
Report Date: 11/20/2022
Date Signed: 11/27/2022 09:36:25 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/27/2022 09:36 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:
11/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH: Amelie Diouf and Jemimah GithuaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with the Staff and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 113.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. However, the fire extinguisher is outdated. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA 5 reviewed resident, during the file review LPA observed 3 of 5 outdated service plans (IPPs) and 2 staff files, including criminal record clearances. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. Fire drill was conducted on 10/31/22.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2022
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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Document Has Been Signed on 11/27/2022 09:36 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/20/2022 at 03:33 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MICHAEL'S RESIDENTIAL HOME CARE
FACILITY NUMBER: 397203009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2022
Section Cited
CCR
80068.2(b)(1)

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80068.2(b)(1)If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided
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Facility will obtain a current IPP, not more than a year old. Facility will furnish LPA with a current, recent IPP for the identified individuals. By the POC date 12/15/2022
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that:(1)The needs appraisal or IPP is not more than one year old. Based on records review and observation R1, R2 and R3's IPP are outdated.
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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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


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Document Has Been Signed on 11/27/2022 09:36 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/20/2022 at 03:50 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MICHAEL'S RESIDENTIAL HOME CARE
FACILITY NUMBER: 397203009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2022
Section Cited
CCR
80020(a)

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80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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Administrator shall replace battery and ensure smoke detector functions properly and have the fire extingushier serviced by close of business of POC date.
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Smoke detector in hallway is in need of service and the fire extingushier is outdated.
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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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


LIC809 (FAS) - (06/04)
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