496803933-8-18-2021-21-AS-BMOS-C68LSL-20210825090054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803933
Report Date: 08/18/2021
Date Signed: 08/18/2021 11:53:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210713140557

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: 6	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Chris Cardenas - Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility is not adhering to admission agreement signed by residents.

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes & Hansen arrived unannounced for the purpose of closing the investigation and met with Chris Cardenas - Administrator.

On 7/15/2021, LPA Fernandes-Goes & Hansen toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of facility with staff Celine Mirasol & Teresita Bulau; interviews with 6 of 6 residents responsible parties, staff, and other individuals involved on 7/14, 7/15, & 8/13/2021, LPAs learned that residents' POAs were requested during a meeting at the facility in the end of June 2021 to make all checks for July payable to St. Francis. Facility is under St. Michael’s license and licensee responsible for its operation is Marilyn Green. St. Michael’s after CHOW kept remaining on file admission agreements for 4 residents in care.
(continue LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210713140557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/18/2021

NARRATIVE

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Agreements on file under license facility are to have all payments made to St. Michael/Marilyn Green.

According with complaint allegation “Facility is not adhering to admission agreement signed by residents'.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210713140557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B 09/01/2021 Section Cited CCR 87507	1 2 3 4 5 6 7	87507 Admission Agreements: This requirement has not been met as evidence by:Based on file review & interviews, the licensee did not comply with the section cited above in 4 out of 4, adm agreement of residents in	1 2 3 4 5 6 7	Licensee agrees to have admissions agreement updated according with Title 22 Regulations under St. Michael license facility on file for all residents and have all payments made to license/licensee as
	8 9 10 11 12 13 14	care which poses a potential personal right risk for residents in care. Facility residents POAs made payments as requested by fac forJuly to an entity who is not the license facility at this address. (copies & email file)	8 9 10 11 12 13 14	required by law. Licensee to submit to CCL copy of all ad. agreements for residents in care and self-certification that all payments are to be made to St. Michael/ Marilyn Green facility by POC date of 9/1/2021.
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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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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