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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203009
Report Date: 10/09/2024
Date Signed: 10/15/2024 04:14:13 PM

Document Has Been Signed on 10/15/2024 04:14 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/
DIRECTOR:		OGBUEHI-NZAMBI, VICTORIAFACILITY TYPE:
735
ADDRESS:5125 JETTY DRIVETELEPHONE:
(209) 234-2215
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
10/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Victoria Ogbuehi-NzambiTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Unannounced case management visit made out to this facility on 10/09/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregiver, Loveth Ogbuehi, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Victoria Ogbuehi- Nzambi, to inform her that CCL was present at this time.
The facility designated Administrator arrived shortly thereafter to this facility. An interview was conducted with the facility designated Administrator at this time.
Current census was (5) residents , of which all of them, were out of the facility at this time at their respective day programs at this time.
The purpose of this case management visit was to discuss an incident that was reported to this department and gather additional forms and documents related to this incident.
The following forms and documents were requested by this LPA at this time:

Admissions Agreement for R1
LIC 602 for R1
Needs/Appraisal forms for R1
Most current IPP from Valley Mountain Regional Center (VMRC) for R1
ID/Emergency for R1
Medication Administration Record (MAR) for R1

There were no deficiencies observed or cited during today's case management visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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