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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 01/20/2023
Date Signed: 01/20/2023 03:15:27 PM


Document Has Been Signed on 01/20/2023 03:15 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: 5DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Chris Cardenas, Administrator & Marilyn Green, LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced - required 1 yr. infection control inspection to this facility and was welcome by staff Ocito Delparto and met with Administrator Chrisante Cardenas who arrived during this visit, and Licensee Marilyn Green who arrived 30 minutes later. Facility has 5 residents, 2 with dementia and none on hospice.

LPA conducted tour of facility on1/20/2023 at 1:40pm 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 8/24/2022 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 119.5 degrees F and 115.7 degrees F which is within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. Medication are centrally stored in the Livingroom. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility. The facility serves residents with dementia and has a plan of operation for special care and programming. Disaster Drills had been conducted quarterly last being done 10/16/2022.

Infection Control:


Facility has submitted a mitigation program plan and Infection Control Plan. 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. All staff had masks on during this visit.

Continued LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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: 01/20/2023
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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.

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 current CPR & 1st Aid certification for staff.
Administrator Certificate is for Crisante Cardenas # 6025751740 Exp. 03/24/2023
All staff and residents are 100% vaccinated for COVID 19

There were no deficiencies cited at this time

LPA Hansen is requesting Licensee to update and submit the following documents by 02/03/2023 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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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