397203009-5-7-2025-27-AS-NWPN-DGFTML-20250507145118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397203009
Report Date: 05/07/2025
Date Signed: 05/07/2025 02:51:27 PM

Document Has Been Signed on 05/07/2025 02:51 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 CARE		FACILITY NUMBER:	397203009
ADMINISTRATOR/ DIRECTOR:	OGBUEHI-NZAMBI, VICTORIA		FACILITY TYPE:	735
ADDRESS:	5125 JETTY DRIVE		TELEPHONE:	(209) 234-2215
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 5	DATE:	05/07/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:08 PM
MET WITH:	Amelie Diouf		TIME VISIT/ INSPECTION COMPLETED:	03:15 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	On 5/7/25 at 2:00, Licensing Program Analysts (LPAs) Noel Wolf Petersen and Michael Bilger arrived unannounced at the facility to conduct a case management related to a recent death of a resident. LPAs were met by Direct Support Provider Amelie Diouf , and explained the purpose of the visit. Based on review by the department regarding the death of Resident 1 (R1), it was determined that R1 passed away on 10/5/2024 at the facility. R1’s Death Certificate, indicated R1’s cause of death was due to deep vein thrombosis (DVT), kidney failure, and hypertension. R1 was seen multiple times at Acute Hospital Emergency Room on 10/2/2024 and on 10/3/2024. R1 was initially discharged on 10/2/2024 and prescribed medication to help R1’s DVT and prevent a pulmonary embolism from occurring as that could lead to death. In an interview with the department, Witness 1 (W1) recalled explaining to Staff 1(S1) the importance of giving R1 the medication after each ER visit. The medication logs obtained by the department investigator showed that R1 took the medication on 10/3/2024 and on 10/4/2024. In an interview the department, W1 stated that she was unable to determine that with or without the medication, R1’s death could or could not have been prevented. The investigation further determined through interview with W1, that R1 had several other health issues that could have contributed to her death. W1 felt that the three pills R1 took on 10/3/25 and 10/4/25 should have affected her DVT by improving and preventing any further blood clotting in her arms. W1 further explained in an interview with the department that there could have been multiple contributing factors into R1’s death. Continued on C-Page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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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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: 05/07/2025

NARRATIVE

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As a result, there is not a preponderance of evidence to conclude R1’s death was the result of facility staffs’ neglect or lack of care and supervision.

During today’s case management regarding following up the death investigation, the Physical Plant was inspected, including but not limited to the garage, recreational areas, client bedrooms, client bathrooms, storage areas, exteriors, evacuation routes, and kitchen. The first aid kit was found to have the necessary items, and the clients bathroom wash water was measured at 107*F as required to be between the 105-120*F thresholds. The fire/CO alarm’s were found to be in working order, and the medications and sharps were locked and away from residents in care. The required posters were found to be the appropriate size and in appropriate locations for access by the applicable parties. This facility is licensed to serve six(6) developmentally disabled adults between the ages of 18-59 and two(2) of the clients may be non-ambulatory.The garage was clear of stored medication.

Based on interviews and record reviews regarding this case management investigation, no citations {or citations} are issued and this case management is closed. An exit interview was conducted with DSP Amelie Diouf and a copy of this report was provided. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC809 (FAS) - (06/04)

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