496803933-2-24-2022-21-AS-SHAN-CBXQAU-20220224110030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:00:37 AM

Document Has Been Signed on 02/24/2022 11:00 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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:	02/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Crisante Cardenas - Administrator		TIME COMPLETED:	11:00 AM

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	Licensing Program Analyst (LPA) Hansen conducted an unannounced - required 1 yr. infection control inspection to this facility and was welcome by staff Jocelyn Llorca and met with Administrator Chrisante Cardenas who arrived during this visit. Facility has 6 residents present, 2 with dementia and none on hospice. LPA arrived at the facility and had temperature checked and logged into visitor’s binder. During facility tour on 2/24/2022 with Chrisante Cardenas Administrator facility was found at a comfortable temperature with all exits free from obstruction. Sample of resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/19/2021 at the time of the visit. Sample test of Smoke detectors and carbon monoxide detector was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in laundry room. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. Resident’s bedrooms that were inspected had lighting & appropriate furnishings. Hot water temperature measured between 140.1 degrees F and 121.8 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 2/24/2022 at 10:00 AM. (see LIC 809-D) The facility serves residents with dementia, and has a plan of operation for special care and programming. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the dinning room area. Facility has hired and admitted new residents and staff since COVID-19. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility. All staff had masks on during this visit. Continued LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ST. MICHAEL ASSISTED LIVING	FACILITY NUMBER: 496803933
	VISIT DATE: 02/24/2022

NARRATIVE

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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents also have available telephone calls when contacting with family members and others. Staff had all PPE training required on file and are scheduled today to have N-95 fit testing conducted by LPH.

In addition, LPAs advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills had been conducted quarterly last being done 12/2021.

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/16/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/24/2022 11:00 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ST. MICHAEL ASSISTED LIVING	FACILITY NUMBER: 496803933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 1 of 2 resident's bathrooms which poses an immediate Health, Safety risk for esidents in care. LPA toured the facility with Administrator Chrisante Cardenas on 2/24/2022 at 10:00 AM & observed that hot water temperature ranged between 140.degrees F and 140.1 degrees F.
	POC Due Date: 02/25/2022
	Plan of Correction
1 2 3 4	Licensee to ensure water temperature is maintained within regulation - 105 TO 120 F. Licensee to submit a LIC 9098 seff certification that hot water temperature is within regulation by POC date of 2/25/2022 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 3/3/2022. Staff during the tour of the facility has adjusted hot water 7 day log still required to be submitted to CCL by 3/3/2022.

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC809 (FAS) - (06/04)

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