<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 08/01/2022
Date Signed: 08/01/2022 02:06:27 PM


Document Has Been Signed on 08/01/2022 02:06 PM - 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 LIVINGFACILITY NUMBER:
496803933
ADMINISTRATOR:CARDENAS, CRISANTE MFACILITY TYPE:
740
ADDRESS:804 ST. FRANCIS STTELEPHONE:
(707) 763-8289
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
08/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Cris Cardenas (Administrator)TIME COMPLETED:
02:15 PM
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) Cuadra conducted an unannounced case management and met with Crisante Cardenas Administrator. The purpose of this case management inspection is to follow up on a self reported incident submitted to Community Care Licensing (CCL) on 7/18/2022.

CCL received an incident report on 7/18/2022. Per incident report, on 7/11/22 at around 7:30am staff noticed that resident (R1) was not in their baseline, weaker than normal, dizzy and confused. Staff immediately called 911 and R1 was transported to Santa Rosa Kaiser Hospital. R1 came back home discharged from the hospital on 7/14/22. Discharge documents were also submitted along with incident report indicating a referral for home health for wound care due to a community-acquired right heel pressure ulcer Stage 2.

During today's visit, LPA reviewed records, made observations, interviewed staff and was provided with a podiatry follow up evaluation performed on 7/22/22 were R1 was assessed with DM2 peripheral neuropathy, healed lateral right heel ulcerations and Stage 1 ulceration right lateral malleolus. Per records review, there is an agreement signed by National home health agency to provide wound care for restricted health condition. Home health nurse is overseeing wound care for R1 three times per week in average. LPA also obtained R1's care plan dated 2/18/22 and medical assessment dated 2/11/22 indicating that R1 has a history of skin conditions. LPA will review documentation obtained and evaluate if further documentation is needed.

LPA provided Administrator with regulation 87612 and 87631 for reference on healing wounds and who can treat them. Administrator agreed to review regulation to ensure compliance with Title 22 regulations.

No deficiencies cited at today's visit. Exit interview conducted with Administrator and copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1