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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 02/09/2021
Date Signed: 02/10/2021 09:21:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ST. MICHAEL ASSISTED LIVINGFACILITY NUMBER:
496803933
ADMINISTRATOR:EVANGELISTA, JONALDFACILITY TYPE:
740
ADDRESS:804 ST. FRANCIS STTELEPHONE:
(415) 342-2562
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
02/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marilynn Green - LicenseeTIME COMPLETED:
06:00 PM
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Licensing Program Analysts (LPAs) Fernandes-Goes conducted an unannounced virtual pre-licensing inspection. LPA contacted licensee Marilynn Green & administrator Astrid Morancil through a telephone call and started a tele-visit inspection due to COVID-19. This is a change of ownership (CHOW). Fire clearance has been approved for 6 non-ambulatory residents. There is no Hospice Waiver on file at this time, Dementia Program Plan has been approved by the application unit. LPA will conduct a component III orientation with licensee Marilynn Green & administrator Astrid Morancil. There is a total of 6 residents with no residents under Hospice. Facility has a hospice waiver for 2.

St. Michael Assisted Living is a program for senior residents. The facility has been approved for 6 non-ambulatories by Sonoma Fire Department. Facility plans on having awake staff; there will be 2 shifts of staff at the facility at all times, as per licensee Marilynn Green & administrator Astrid Morancil

LPAs toured facility with licensee Marilynn Green & administrator Astrid Morancil on 2/9/2021 at 2:30 PM and observed: Facility is a one floor building. The facility was inspected and found to be cleaned and at in good repair. Exits were equipped with auditory devices were activated at the time of the visit; licensee/administrator understands that auditory devices must be on at all times. Fire Extinguisher was found to be last charged on 08/2021 at the time of the visit. Smoke detectors and carbon monoxide detector were found to be working at this time. Hot water temperature checked 97.4 degrees F which doesn’t meet the regulation requirement of hot water temperature between 105- & 120-degrees F. LPA is requesting a 4 day hot water temperature log from both resident’s bathrooms.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ST. MICHAEL ASSISTED LIVING
FACILITY NUMBER: 496803933
VISIT DATE: 02/09/2021
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The facility has a phone line designated for resident’s use. There was an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cookware as per facility. There were emergency supplies available at the time of the visit.

Personnel records and resident’s records are stored at the facility in a locked cabinet in dining area. The floor includes kitchen, living room area, resident’s bedrooms, staff room, 2 resident’s bathroom and 1 staff bathroom, dining room, laundry, and garage. Resident's bedrooms have all required lighting & appropriate furnishings as per Title 22 Regulations. Activities are available for residents as per licensee and administrator. Resident records, medication will be locked on this level in cabinet, toxins are kept locked in a designated cabinet in the garage; facility has first aid kit. There is outdoor space for activities.

A virtual review of six resident & two staff records was conducted. LPA reviewed resident’s files and learned that 6 of 6 residents have an updated physician’s assessment – LIC 602 and cleared TB test results. Medications were not reviewed at this time due to visit being conducted virtually. Licensee & Administrator understands that all medications must have a doctor’s order and medication must match the order. As per licensee/administrator all medication has a doctor’s order. LPAs reviewed a sample of staff records and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions under the facility that is licensed at this time. In addition, sample review of staff file shows that Direct care staff additional training requirements are on file. LPAs were presented with proof of CPR & 1st Aid certification for sample staff files that were reviewed virtually. Disaster Drills are conducted monthly, and last drill dated 12/12/2020.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021
LIC809 (FAS) - (06/04)
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