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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 03/14/2023
Date Signed: 03/14/2023 12:40:34 PM


Document Has Been Signed on 03/14/2023 12:40 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:
03/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marilyn Green, Licensee.TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced for the purpose of conducting a health check inspection and met with Licensee Marilyn Green. LPA observed 2 staff on duty upon arrival to the facility. Staff Epi contacted the Licensee regarding LPA’s arrival. Licensee arrived at the facility to meet with the LPA.

This case management inspection is to conduct a health and safety check and ensure there is staffing on-site.

LPA toured the facility and there were no observed health and safety hazards, home was clean at a comfortable temperature and well-lit for resident’s safety. The facility was observed to have cable television, phone services, PG & E services, all utilities were observed to be on during the inspection. There was at least a 2-day supply of perishable and 7-day supply of nonperishable foods available to residents. Staff were observed assisting residents and were readily available to provide care.

LPA observed residents comfortable watching television or in their bedrooms resting.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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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