496803933-11-1-2021-21-AS-KMOA-C8FU64-20211104151742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803933
Report Date: 10/22/2021
Date Signed: 11/01/2021 03:15:49 PM

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
09/09/2021 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20210909091242

FACILITY NAME:	ST. MICHAEL ASSISTED LIVING		FACILITY NUMBER:	496803933
ADMINISTRATOR:	CARDENAS, CRISANTE M		FACILITY TYPE:	740
ADDRESS:	804 ST. FRANCIS ST		TELEPHONE:	(707) 763-8289
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 6	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Crisante Cardenas & Licensee Marilyn Green		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injuries while in care.
Facility did not notify physician of changes in resident's health.
Facility did not seek timely medical attention for resident.
Staff are not following hospital discharge orders for resident's care.
Resident eloped from facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of a subsequent complaint investigation resulting in delivering findings of the above allegations. LPA met with Crisante Cardenas, Administrator and Marilyn Green, Licensee.

During the investigation LPA reviewed records, made observations at the facility and conducted interviews.

Complaint alleges resident (R1) sustained injuries while in care. - LPA has conducted interviews, made observations, and obtained legal and medical documents. Records indicate that R1 sustained self-inflicted scratches on R1’s arm with a red marker. Investigation also revealed R1s complaint of elbow pain was due to an infection, which was diagnosed by an ER physician on 9/8/2021. This allegation is unsubstantiated.

Continue on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 21-AS-20210909091242

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: 10/22/2021

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

Facility did not notify physician of changes in resident’s health. -& Facility did not seek timely medical attention – R1 was discarded from hospital on 7/28/2021 with a follow up appointment made for 8/9/2021. R1 was admitted to the facility on 7/28/2021 and records indicate R1 was seen in person on 8/9/2021, 9/1/2021, 9/7/202, and 10/4/2021 by doctors and had video/phone appointment on 8/20/2021, 8/27/2021, & 9/2/2021. It was also disclosed facility made many attempts to get R1 in person appointments with their primary care physician and when this did not take place R1 was seen in ER 9/1/2021 & 9/7/2021. Evidence does not support allegations that facility did not notify physician of changes in resident's health and or seek timely medical attention for R1. These allegations are unsubstantiated.
Staff are not following hospital discharge orders for resident. – Record review indicates that R1’s hospital discharge orders state that R1 is to apply ice, cream, and use a sling as much as possible after R1 was seen in ER on 9/8/2021. LPA learned through interviews and observation that after R1s discharge, R1 kept rubbing their elbow in bed (wiping the cream off) and taking the sling off and refusing to wear the sling, as well as R1 had difficulty leaving the ice pack on their elbow very long. The allegation is unsubstantiated.

5 Resident eloped from facility. Review of R1s medical records indicated resident could leave the facility unassisted. The allegation is unsubstantiated.

This Department has investigated this complaint and determined that although the allegations Resident sustained injuries while in care, that facility did not notify physician of changes in resident's health, facility did not seek timely medical attention for resident, staff are not following hospital discharge orders for resident's care, and that resident eloped from facility may be true or valid, there is not a preponderance of evidence to prove the alleged violation did or did not, occur. Therefore, the allegation is deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2