496803933-3-29-2022-21-AS-BMOS-CD8NA2-20220406101650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803933
Report Date: 03/28/2022
Date Signed: 03/29/2022 12:57:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220301110907

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:	03/28/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Chris Cardenas		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's personal belongings were not safeguarded while in care.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegation. LPA met with Administrator and discussed the findings. Complainant alleges that a walker belonging to R1 was not returned to the Responsible Person following the death of R1. Licensee states that the walker cited by the Complainant was not on the premises at the time the License took over the care of the facilities residents. During the course of this investigation, statements were taken, sit visits made, and documents reviewed. The following determinations are made: The walker in questions was not observed during site visits to the facility; Complainant does not recall when the walker was last observed by the Complainant; the property inventory for R1 does not adequately describe the walker and, therefore, cannot be distinguished from walkers currently on the premises. Although the allegation may be true, based upon the visits, statements, and reviewed documents, there is not a preponderance of evidence to prove the allegation is, or is not, valid. Therefore the allegation is UNSUBSTANTIATED

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220301110907

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:	03/28/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Chris Cardenas		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Admission Agreement was not adhered to.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint allegation. LPA met with Administrator and discussed the findings. Complainant alleges that the admission agreement was not followed in terms of the refund to the Responsible Person following the death of R1. This Department has investigated the allegation by making site visits, reviewing documents and taking statements. The following determinations are made: The current facility license was granted to the Licensee on March 05, 2021, although the Licensee was managing the facility since July 01, 2020; the most current Admission Agreement between the facility and R1 is dated August 24, 2021; The Admission Agreement indicates rent of $4000.00 and that payment is due on the 8th of the month; A previous Admission Agreement dated July 06, 2020 indicates rent of $3200.00 with payment due on the 6th of the month; Licensee states that residents were advised on July 01, 2020 that monthly rental fees are calculated from and due on the first of each month; Licensee and RP agree that R1 belongings were removed from the facility on 11/10/2021; Licensee has refunded $3000 of November’s rent; RP claims to be due an additional $800.00 in refund; Licensee claims rent owed for 10 days in November; RP claims rent is due for 4 days in November;
*****continued**********

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20220301110907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2022

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 Department has determined, based on documents and statements, the Licensee is due rent for 3 days in November at $400; refund due to RP is $3600 in accordance with Admission agreement signed August 24, 2021. Therefore, the allegation is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) 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.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220301110907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/12/2022 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507(f)ADMISSION AGREEMENTS. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.***This requirement not met as evidenced by: Based upon statements and documents, Licensee did not refund the total amount due following the termination of residency of R1 at the facility.	1 2 3 4 5 6 7	Licensee will refund the Responsible Person for R1 in the amount of $600.00 for a total of $3600, $3,000 of which has been paid previously. Proof of payment due by POC date in order to clear the deficiency.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4