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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803933
Report Date: 04/28/2023
Date Signed: 04/28/2023 02:22:14 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
01/31/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230131081425
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: 4DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marilyn Green, Licensee TIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not communicate with resident's authorized representatives
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations and met with Licensee Marilyn Green. There are currently 4 residents at the facility, 1 is in the hospital.

Licensee did not communicate with resident’s authorized representatives – Complainant alleges the licensee is not communicating with the residents or their families regarding their admission status at the facility. The department interviewed the reporting party who confirmed they had been in contact with the licensee regarding the allegations. There had been inconsistent statements from both reporting party, licensee, and staff regarding eviction or facility closure. There is not enough corroborating evidence to support the allegation the licensee did not communicate with the resident’s authorized representatives.

Although the allegation may be true or valid, there is not a preponderance of evidence to prove that the allegation is, or is not, true. Therefore, the allegation is found to be UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
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
01/31/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230131081425

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: DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marilyn Green, Licensee TIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations and met with Licensee Marilyn Green. There are currently 4 residents at the facility, 1 is in the hospital.

Illegal eviction – Reporting party indicates in complaint residents are being given illegal eviction and reporting party has received no communication from licensee. The department conducted interviews with reporting party, licensee, and residents, obtained documents and made observations. The reporting party informed the department on 1/31/2023 it was not the residents who had received illegal evictions but possibly the facility. Further interviews with residents also revealed there had not been any eviction notices given. This agency has investigated the complaint alleging facility has given residents an illegal eviction.
We have found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2