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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203009
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:00:15 PM

Document Has Been Signed on 11/07/2023 03:00 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 CAREFACILITY NUMBER:
397203009
ADMINISTRATOR:OGBUEHI-NZAMBI, VICTORIAFACILITY TYPE:
735
ADDRESS:5125 JETTY DRIVETELEPHONE:
(209) 234-2215
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amillie DioufTIME COMPLETED:
03:15 PM
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On 11/7/23 at approximately 10am Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Amellie Diouf 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, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 4 bedrooms and 3 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 6 ambulatory residents.

Facility Observation: Upon entry the residents were away at day program. Resident rooms had personal items including but not limited to photos, posters, artwork jewelry and clothing. Rooms and closets were tidy and the beds were made. Dining table had labeled place mats. Staff were cleaning and making dinner.

During this inspection 2 resident files and 1 staffing file were reviewed for regulatory compliance.
Staff 1 was missing training for 2222 and 2023 and had an expired CPR/ first aid certificate. Staff 2’s file was not at the facility. LPA spoke to administrator by phone. Administrator will email required documents. LPA Fain was unable to ascertain if the staff on duty were associated to the facility.

Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.

Water temperature in common bathroom reads 110.3* F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 70*F.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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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
FACILITY NUMBER: 397203009
VISIT DATE: 11/07/2023
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LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 11/21/22. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. Facility conducts monthly fire drills.

LPA requested an updated copy of LIC 500, LIC 308, LIC 402, LIC 610D, and Current Liability Insurance to be emailed to Jennifer.Fain@dss.ca.gov

The facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D pages. An exit interview was conducted with Amelie Diouf and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2023 03:00 PM - It Cannot Be Edited


Created By: Jennifer Fain On 11/07/2023 at 02:25 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: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80044(c)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not ensure staff file for the administrator and Staff 2 were available at the facility which poses a potential Health, Safety and Personal Rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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Licensee will email required documents to Jennifer.fain@dss.ca.gov by Plan of Correction Date.
Type B
Section Cited
CCR
80075(f)

(f) Health Related Services - Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not ensure Staff 1 had a current First Aid/CPR certificate which poses a potential Health, Safety and Personal Rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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Licensee will email current First Aid/ CPR certificates to jennifer.fain@dss.ca.gov by Plan of Correction date.
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:Liza King
LICENSING EVALUATOR NAME:Jennifer Fain
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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