496803933-7-15-2021-21-AS-SHAN-C4Y3BE-20210715180613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 07/15/2021
Date Signed: 07/15/2021 06:06:28 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 LIVING		FACILITY NUMBER:	496803933
ADMINISTRATOR:	MORANCIL, ASTRID		FACILITY TYPE:	740
ADDRESS:	804 ST. FRANCIS ST		TELEPHONE:	(707) 763-8289
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 4	DATE:	07/15/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Marilyn Green		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Hansen & Fernandes-Goes conducted an unannounced Post Licensing - Infection Control inspection to this facility and was welcome by staff Celine Marisol and met with licensee Marilyn Green who arrived during this visit. Facility has 4 residents present. During facility tour on 7/15/2021 with staff Celine Marisol facility was found to be clean and at a comfortable temperature with 1 out of 4 exits obstructed. LPAs observed a bed blocking the exit door and after removing bed staff, licensee, and LPAs attempt to open door from inside and outside, however; door is locked shut. (see picts, LIC 809-D, Civil Penalty) Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was last inspected on 8/2020. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Dangerous items were stored inaccessible to clients in a closet in the laundry room with exception of medications. Residents’ medications were placed in an unlockable file cabinet in open dining room by kitchen. (see picts, LIC 809-D) There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Resident’s files were not all available for the Department to review during this visit. Per licensee files are being kept electronically and the computer and files were not available during this visit. (LIC 809-D) Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the closet, front office area, and garage. Facility has hired and admitted new residents and staff since COVID-19. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Continued LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 496803933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 4, fire exit door. Fire exit door is unable to open, which poses an immediate health, safety or personal rights risk to persons in care. During toured of the facility with staff Celine, LPAs observed a hospital bed blocking the exit door which was moved to allow passageway to Exit. Once exit was no longer obstructed, LPAs, staff, and/or licensee were not able to open the door from inside or outside. (see picts) Civil Penalty
	POC Due Date: 07/16/2021
	Plan of Correction
1 2 3 4	Licensee understands that all exit doors must not be obstructed and should be able to open. Facility licensee agrees to fix door to ensure door is functioning appropriated by POC date of 7/16/2021. Licensee to submit to CCL pictures with door open and LIC 9098 self certification by 7/16/2021.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 unlocked medication file cabinet which poses an immediate health, safety or personal rights risk to persons in care. Medications are being kept in an unlockable file cabinet in common area in dinning room next to living room and kitchen. LPAs observed medications for all residents stored in accessible file cabinet to all.
	POC Due Date: 07/16/2021
	Plan of Correction
1 2 3 4	Licensee understands that all centrally stored medications must 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 medications. Licensee agrees to have all medications locked. POC date 7/16/2021. Licensee to submit to CCL pictures and LIC 9098 self-certification with medications in new lockable space.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 496803933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(f)(1)

Incidental Medical and Dental Care Services

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents files which poses/posed a potential health, safety or personal rights risk to persons in care. During todays visit LPAs asked licensee for the residents files and licensee informed LPAs they are kept on an electronic file on the computer, which licensee does not have access to.
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	LIcensee understands that all Residents files are to be kept available at the acility at all times and for three years after they pass or move out. POC to be completed by 7/29/2021 with records being available. and send us an LIC 9098 self certification.

Section Cited

Resident Records


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

Page: 3 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 496803933
	VISIT DATE: 07/15/2021

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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents also have available telephone calls when contacting with family members and others. Staff had all PPE training required on file and are working toward obtaining N-95 fit testing.

In addition, LPAs advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills had been conducted quarterly last being done 3/28/2021.

Licensee has notified the Department that she will be remaining open, she is rescinding her closure plan and eviction notices previously issued to families. Licensee will be on property the remainder to today and tomorrow as she onboards new staff and ensure they have training on her program plan, evacuation plan, medication plans, etc. Licensee understands all staff must have an active criminal record clearance and are associated to the facility. Licensee understands there MUST be adequate staff at all times (24/7) to meet the needs of the residents in care.

Immediate Civil Penalties are being assessed in the amount of $500.00 due to zero tolerance citation issued.

******Total Civil Penalties issued today in the amount of $500.00.

Appeal of Rights Given.
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.
There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

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