496803933-6-16-2023-21-AS-HDBI-CSYS67-20230620133528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803933
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:09:35 PM

Unsubstantiated

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
05/15/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230515124124

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: 0	DATE:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee, Marilyn Green		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Neglect/lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA called licensee to meet at facility and waited approximately 35 minutes for licensee to arrive. There are currently no residents at the facility. Licensee had given lawful, 60-day, eviction notices to all residents in care with last day being May 15, 2023.

During this investigation, the department reviewed documents, made observation’s and conducted interviews.
Complaint alleges resident (listed as R1 on LIC811) was to be discharged from a local hospital and licensee failed to accept resident back. On 5/11/2023 R1 was sent out to the hospital, by facility staff, due to medical concerns (which facility reported timely via an Incident Report). At some point in the late afternoon on 5/11/2023 the local hospital attempted to have R1 transported back to the facility. There were no staff at the facility when this occurred resulting in R1 being transported back to the local hospital. Interviews with the licensee revealed that at no time was the Licensee contacted alerting her that R1 was to be returned to the facility.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230515124124

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: 06/16/2023

NARRATIVE

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The Licensee had previous conversations related to R1’s transport to the ER with R1’s family who advised that R1 would remain at the hospital until their scheduled procedure.
Based on an interview with R1’s family member, they corroborated the plan was for R1 to remain in the hospital until date and time of surgery, which was scheduled on Monday of the following week. R1’s family member came to facility and picked up R1’s belongings on 5/12/2023. LPA interviewed the discharge planner from the local hospital R1 was taken to and was not able to verify Licensee was contacted prior to EMT’s transporting R1 back to the facility from their hospital visit.
Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

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