496803933-8-18-2021-21-AS-BMOS-C6DQ6Q-20210830115352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803933
Report Date: 08/18/2021
Date Signed: 08/18/2021 11:57:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210727133445

FACILITY NAME:	ST. MICHAEL ASSISTED LIVING		FACILITY NUMBER:	496803933
ADMINISTRATOR:	MORANCIL, ASTRID		FACILITY TYPE:	740
ADDRESS:	804 ST. FRANCIS ST		TELEPHONE:	(707) 763-8289
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 6	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Chris Cardenas - Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff residing in the unconverted garage of the facility.

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analysts (LPAs) Fernandes-Goes and Hansen arrived announced for the purpose of closing the investigation and met with Chris Cardenas.

On 8/5/2021 at 07:30 AM, LPAs Fernandes-Goes and Hansen toured facility, conducted interviews, reviewed files, acquired documentation; and made observations of the facility. During tour of the facility, fire clearance dated 10/22/2020, and interviews with staff and licensee Marilyn Green, LPAs learned that facility garage has been converted to staff room, bathroom, laundry, and storage. At the time of the visit there were 2 staff with their 2 children sleeping in the staff room. Fire Clearance dated 10/22/2020 has been cleared for the above and does not specify how many people can sleep in staff room. In addition, all staff at the facility were fingerprint cleared and associated to the facility during this visit. (Continue LIC 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210727133445

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/18/2021

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 26 27 28 29 30 31 32	This agency has investigated the complaint alleging "Staff residing in the unconverted garage of the facility.” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC9099 (FAS) - (06/04)

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