496804057-5-18-2023-21-AS-CMAZ-CSSLGB-20230614084429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804057
Report Date: 05/18/2023
Date Signed: 05/18/2023 06:23:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230127163959

FACILITY NAME:	ST. MICHAEL ASSISTED LIVING 2		FACILITY NUMBER:	496804057
ADMINISTRATOR:	CARDENAS, M CRISANTE		FACILITY TYPE:	740
ADDRESS:	7300 BURTON AVE		TELEPHONE:	(707) 242-3086
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS: 5	DATE:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Marilyn Green-Licensee		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff do not provide privacy to residents in care.
Staff do not follow resident's dietary needs.
Staff leave residents soiled for an extended period due to inadequate staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Alviso, conducted a complaint inspection and met with Licensee Marilyn Green.

LPAs reviewd 6(six) of six(6) resident files. LPA reviewed five(5) staff files. LPA conducted interviews with five(5)staff, and other interested parties. LPA toured the facility with the Licensee. The investigation revealed that some residents, four(4), receive incontinent care services. The residents have care plans in place, and staff are trained in using the hoyer lift. In review of resident records, only one(1) out of six(6) residents had a pressure injury; This resident(R3) was admitted into the facility from a rehabilitation facility. R3 had wound care services being provided by medical professionals. The investigation revealed that there was differing information from staff, and other parties interviewed, and obtained information didn't support that a violation had occurred.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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-20230127163959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ST. MICHAEL ASSISTED LIVING 2	FACILITY NUMBER: 496804057
	VISIT DATE: 05/18/2023

NARRATIVE

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Per interviews with staff, and other interested parties, S1, S2, S3, S4, S5, S6, S7, staff stated they provide privacy to residents when providing care needs. The investigation revealed that there was differing information from staff, and other parties interviewed, and obtained information didn't support that a violation had occurred.

The LPA inspected the food supply on both inspection dates, 2/1/23 & 5/18/23, and LPA observed a large sufficient supply of perishable and non-perishable foods. The LPA observed on both inspection dates the staff preparing meals for residents in care. The food supply had fruits, vegetables, and meats in the freezer that needed to be prepared and cooked for meals. Per interviews with staff, the facility staff were aware of providing foods with no seasoning salt, and no sugar added. Per interviews with staff, staff cooked resident(R1) meals that were not seasoned, and food was cooked to resident's instructions. Investigation revealed there was differing information from staff, and other parties interviewed, and obtained information didn't support that a violation had occurred.

Based on LPA's investigation, record reviews, and interviews with staff, and information obtained during interviews with other related parties, there was no information obtained to support that a violation(s) occurred, the allegations of "Staff leave residents soiled for an extended period due to inadequate staffing, Staff do not provide privacy to residents in care, Staff do not follow resident's dietary needs" are unsubstantiated.

Based on observations, record reviews, and interviews with staff and other parties, there is insufficient information to support that violations occurred. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies cited.
Exit interview conducted with Licensee Marilyn Green.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

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