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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202339
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:55:46 AM


Document Has Been Signed on 04/15/2024 11:55 AM - 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 HOMEFACILITY NUMBER:
435202339
ADMINISTRATOR:AGUILAR, DEBBIE R.FACILITY TYPE:
740
ADDRESS:86 CASHEW BLOSSOM DR.TELEPHONE:
(408) 623-4832
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 5DATE:
04/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator, Debbie AguilarTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit and met with Administrator (ADM) Debbie Aguilar. LPA Rai stated the purpose of the visit and conducted a health and safety check at the facility.

On April 12, 2024, the Department received an in incident report stating resident, R1 sustained burn injuries after a fire incident at the facility. R1 was transported to the hospital via ambulance.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed construction materials in the backyard. Staff (S1) stated they replaced the flooring in the resident bathroom and the materials will be disposed this afternoon.

LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. During the tour of the kitchen, LPA Rai observed a cabinet with locking capability which is where the facility staff lock the sharps, such as knives. LPA Rai observed the cabinet unlocked during the visit. LPA Rai observed the kitchen was not being used by staff to prepare food and no staff were observed in the kitchen. Staff S1 locked the cabinet during visit.

During the tour of the laundry room, LPA Rai observed a cabinet with locking capability which is where the facility staff lock the chemical solutions, such as laundry detergents. LPA Rai observed the cabinet unlocked during the visit. LPA Rai observed the laundry room was not being used by staff and no staff were observed in the laundry room. Staff S1 locked the cabinet during visit.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: 04/15/2024
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Page 2 of 2.

LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. 1 Out of 5 resident bedrooms (Bedroom #2) was occupied by a bedridden resident. LPA Rai observed the exit door located in Bedroom #2 was blocked by recliner chair and the exit door was not accessible. Staff S1 was not able to move the recliner chair as it was extended to lay flat and required a remote to adjust the setting as it was an electric powered recliner. S1 was able bring down the foot rest of the recliner but the passageway was still not clear. ADM stated they will talk to the family and ensure the passageway to the exit door is clear.

LPA Rai toured the dining room and observed the medication cabinet. LPA Rai observed the cabinet door had locking capabilities but it was unlocked during visit. LPA Rai observed the staff were not administering medications. Administrator locked the medication cabinet during visit.

LPA Rai observed no smoking signs posted around the facility and 1 out of 5 residents observed using oxygen in the facility.

LPA Rai was not able to observe Bedroom #1. Staff S1 stated the resident R2 prefers to lock the room and staff are not able to access the bedroom and was not able to verbalize how staff would be able assist R2 in an emergency. ADM stated they will submit a plan of action to ensure the health and safety of the resident R2.

LPA Rai obtained the following documents: R1's Physician's Report dated 10/21/2023, R1's Appraisal/Needs and Services dated 7/24/2023, R1's Centrally Stored Medication Log and Medication Administration Record (MAR) from July 2023 to April 2024, R1's Admission Agreement, R1's Functional Capabilities Assessment dated 7/25/2023, and R1's After Visit Summary 7/25/2023 and 11/7/2023.

This case management will be kept open pending investigation.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator (ADM) Debbie Aguilar and a copy of the report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/15/2024 11:55 AM - 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: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Licensee/Administrator agreed and understood. Staff S1 locked the cabinet during today's visit
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Based on interview and observation, LPA Rai observed the cabinet containing knives was unlocked and accessible to residents with dementia which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
04/16/2024
Section Cited
CCR87705(f)(2)

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87705 (f) (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Administrator agreed and understood. Staff S1 locked the cabinet during today's visit.
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Based on interview and observation, LPA Rai observed the cabinet containing laundry detergent was unlocked and accessible to residents with dementia which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/15/2024 11:55 AM - 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: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87307(d)(6)

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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Licensee/Administrator agreed and understood.
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Based on interview and observation, LPA Rai observed the area infront of the exit door for a bedridden resident on Hospice services was obstructed by a recliner chair which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
04/16/2024
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Licensee/Administrator agreed and understood. Administrator locked the cabinet during today's visit
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Based on interview and observation, LPA Rai observed the medication cabinet containing the centrally stored medication was unlocked and accessible to persons other than employees and residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4