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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:29:02 PM


Document Has Been Signed on 02/01/2023 04:29 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:
02/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Licensee Marilyn GreenTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA)'s Hansen and Alviso arrived unannounced to conduct a case management at St. Michael Assisted Living on 02/01/2023 and met with Licensee Marilyn Green.

This case management is to cite a deficiency that was observed during a complaint inspection of today 2/1/2023.

LPA's observed medications to not be secured appropriately, making them accessible to residents in care, including staff that do not handle medications and others. This deficiency will be cited, LIC87465 (h)(2)(see LIC809-D).

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.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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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Document Has Been Signed on 02/01/2023 04:29 PM - 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: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2023
Section Cited

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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Licensee to ensure that medications are centrally stored and locked making them inaccessible to residents at all times. Licnesee to submit plan of correction and how the facility will maintain insuring medicaitons are locked per regulations by POC due date 2/2/2023.
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This requirement has not been met as evidenced by LPA's observation while touring the facility, medications were observed by LPA's to not be locked appropriately, making them accisable to residents in care. This is a health and safety as well as personal rights risk to persons in care.
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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
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