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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:17:22 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:CARDENAS, CRISANTE MFACILITY TYPE:
740
ADDRESS:804 ST. FRANCIS STTELEPHONE:
(707) 763-8289
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
08/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Chris Cardenas - AdministratorTIME COMPLETED:
12:17 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Fernandes-Goes and Hansen arrived unannounced with the purpose of closing and opening a new complaint investigation. During subsequent complaint investigation LPAs learned there are deficiencies observed during the visit. LPAs met with Cris Cardenas - Administrator. Following item were observed during this visit:

LPAs observed resident R1 eating egg, sausage/hotdog, and hash brown. During resident's files review and interviews on 8/18/2021, LPAs learned that residents R1, R2, & R3 have a special diet according with medical assessments on file and 2 out of 3 have Diabetes II. (see copies, LIC 812, LIC 809-D) In addition, resident R4 who was admitted to the facility on 7/29/2021 has no pre-appraisal on file and documentation needed still need to be sign. According to administrator interview, facility didn’t conduct a pre-appraisal before admission. (see LIC 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: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2021
Section Cited

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87555(b)(7)General Food Services Reqs:Modified diets prescribed by a resident's physician as a medical necessity shall be provided.This requirement is not met as evidenced by: Based on file review & interviews, licensee
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didn't comply w/section cite above on 3 out of 3 residents in care which poses an immediately health, safety & personal rights risk for residents in care. R1,2,&3 have a special diet which staff wasn't aware of (see copies and interviews)
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Facility to submit plan by POC date of 8/18/2021 in order to clear this citation.
Type B
09/01/2021
Section Cited

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87457(a)PreAdmission Appraisal: Prior to admission, the prospective resident and his/her responsible person... This requirement is not met as evidenced by:Based on file review & interviews,facility didn't
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comply with section cite above in 1 out of 1 new resident admission which poses a potential health, safety & personal rights risk for residents in care. LPAs observed that res R4 admitted on 7/29 has no pre appraisal on file.
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the Department by POC date of 9/1/2021 in order to clear this citation.
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: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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