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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 08/05/2021
Date Signed: 08/05/2021 03:52:03 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: 6DATE:
08/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marilyn Green - LicenseeTIME COMPLETED:
09:50 AM
NARRATIVE
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License Program Analysts (LPAs) Fernandes-Goes & Hansen arrived unannounced to conduct a case management – deficiencies visit to follow up on documentation requested for Plan of Correction (POC) on Post License visit that occurred on 7/15/2021. LPAs were welcomed by Kenneth John - staff. Licensee Marilyn Green was contacted by telephone and arrived at the facility during visit.

LPAs toured the facility, reviewed files, and made observations on 8/5/2021 regarding the following deficiencies:
Title 22 Regulations #87465(f)(1) Type B - Incidental Medical & Dental Care Services - POC Cleared.

Title 22 Regulations #87307(d)(6) Type A - Personal Accomodations & Services - POC Cleared.

Title 22 Regulations #87465 (h)(2) Type A - Incidental Medical & Denatl Care Services - POC Cleared.

Department is requiring the following documentation: LIC 500 Personnel Summary - with the actual hours for all staff and administrator of the facility.

In addition, when LPAs arrived at the facility staff wasn't wearing masks. (POC 809-D) .

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited

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87468.1(a)(2) Personal Rights of Residents in all facilities:Based on LPAs observation on 08/5/21, the staff did not comply with the section cited above in 2out of2 staff failed to wear face coverings while providing care &
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supervision to residents in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions which poses/posed an immediately health, safety & personal rights risk to persons in care.
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understands and is wearing face coverings according with government orders by POC date of 8/6/2021 in order to clear this citation.

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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
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