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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 07/16/2021
Date Signed: 07/16/2021 12:37:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ST. MICHAEL ASSISTED LIVINGFACILITY NUMBER:
496803933
ADMINISTRATOR:MORANCIL, ASTRIDFACILITY TYPE:
740
ADDRESS:804 ST. FRANCIS STTELEPHONE:
(707) 763-8289
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 4DATE:
07/16/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Marilyn Green-LicenseeTIME COMPLETED:
12:37 PM
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Licensing Program Analyst (LPAs) C. Fernandes-Goes & S. Hansen conducted an announced case management visit - health & safety check due to change of facility staff and potential closure of facility and Plan of Correction (POC) follow up on obstructed exit door, and was welcomed by licensee Marilyn Green.

During post licensing visit conducted on 7/15/2021, LPAs learned through staff statement who were at the facility that their last day would be on 7/16/2021 and administrator Astrid Morancil had resigned due to changes in management. In addition on 7/15/2021, facility licensee Marilyn Green notified the Department that she will be remaining open, she is rescinding her closure plan and eviction notices previously issued to families.

Today facility has a staff member and licensee working at facility. Residents were having lunch and as per licensee, new staff and administrator will be starting tomorrow. Licensee Marilyn Green understands that new staff and administrator need to be fingerprint cleared and associated to the facility before working and/or on the facility premises. The following is needed for association of staff - LIC 508, LIC 9182, and copy of active ID.

In addition, LPAs toured the facility and observed Title 22 regulation 87307(d)(6) Personal Accommodations and Services cited on 7/15/2021 type A citation has been cleared. Exit door on room #3 is opening and closing properly and is no longer obstructed. POC CLEARED.
Department is requesting the following documentation for the 4 residents at the facility to be submitted to CCL by 7/19/2021:

Admissions agreements, LIC 602 Medical Assessment, list of medications, and care plans

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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