435202339-3-25-2024-26-AS-MPAA-D3PR7L-20240325124632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202339
Report Date: 03/25/2024
Date Signed: 03/25/2024 12:46:42 PM

Document Has Been Signed on 03/25/2024 12:46 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	SAINT MICHAEL RESIDENTIAL HOME		FACILITY NUMBER:	435202339
ADMINISTRATOR:	AGUILAR, DEBBIE R.		FACILITY TYPE:	740
ADDRESS:	86 CASHEW BLOSSOM DR.		TELEPHONE:	(408) 623-4832
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 6	DATE:	03/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Caregiver/Designated ADM Joselito Garcia		TIME COMPLETED:	12:45 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 3/25/2024 Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Annual required inspection at facility and met with caregivers/designated administrators Joselito Garcia (S1) and Nancy Esteban (S2). Administrator (ADM) Debbie Aguilar is currently out of the country at the time of this visit. LPA accompanied by S1 toured the exterior, and interior of the facility including, but not limited to the following areas, 5 resident bedroom, and 1 staff room, 2 bathrooms, the kitchen, dining, living room and activity area. The facility's room temperature was 73 degree F. LPA inspected the exterior and walkways and pathways were free from obstruction. LPA inspected the kitchen observed, knives were safe and secure in a locked cabinet. LPA inspected the refrigerator and freezer, and observed 2 days' supply of perishable foods, an the pantry has 7 days supply of nonperishable food. LPA observed chemicals, laundry detergents and cleaning supplies are in a separate area and not accessible, water temperature in the kitchen sink is at 105 degree F. LPA observed both staff are attending to the residents' needs, after breakfast, the bedrooms and bathrooms were inspected, all residents' bedrooms were observed free of odor. Beds have pillows, top and bottom sheets, waterproof protectors and blankets. Working light fixtures were observed in all rooms. Bathrooms are equipped with non-slip mats, safety grab bars and shower chairs. Hot water temperature was 105 degree F. page 1 continued to page 2 LIC 809C

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAINT MICHAEL RESIDENTIAL HOME	FACILITY NUMBER: 435202339
	VISIT DATE: 03/25/2024

NARRATIVE

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The facility has a wired fire alarm and also has a carbon monoxide detector and a fire extinguisher was last inspected on 05/10/2023.

LPA randomly selected 3 resident file record for review and observed 3 out of 3 centrally stored medication record (CSM) are up to date. 3 out of 3 residents have current Appraisal/Needs and Services Plans (ANS) on file. A copy of their Admission Agreement and Personal Rights were also on file. 3 out of 3 residents are missing the Consent Forms, and Weight Record, 1 out of 3 resident file record does not have TB test result documented. S1 and S2 stated, they are both new in the facility and have been working for less than 6 months and is not aware of where the other records are filed. S1 has been in the facility for 4 months, and S2 has been in the facility for 1 month.

LPA reviewed facility record and found that the facility disaster preparedness training is up to date.

All staff have criminal background clearance from Community Care Licensing and are listed in the facility's personnel roster. Current first aid certification and training for types of residents served were verified.

During today's visit, a citation is issued per California Code of Regulation, Title 22. An exit interview was conducted with S1 Joselito Garcia, and S2 Nancy Esteban, the designated ADM for the facility in the absence of administrtor Debbie Aguilar. A copy of the signed report and appeals rights was provided.

End of Report
page 2 of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/25/2024 12:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAINT MICHAEL RESIDENTIAL HOME	FACILITY NUMBER: 435202339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85075.4

Observation of the Resident

85075.4 Observation of the Client(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning. (c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents' file record review. The current staff are not able to find the weight records for the resident, which poses/posed a potential health, safety or personal rights risk to persons in care. S2 tried to call ADM but was not successful.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	S1 and S2 stated they will reach out to the administrator who is currently out of the country and ask where the weight records of residents are kept. S1 and S2 or ADM will email proof of correction on or before the POC due date of 4/5/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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