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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804057
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:09:16 PM

Document Has Been Signed on 02/07/2023 01:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 2FACILITY NUMBER:
496804057
ADMINISTRATOR:CARDENAS, M CRISANTEFACILITY TYPE:
740
ADDRESS:7300 BURTON AVETELEPHONE:
(707) 242-3086
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 6DATE:
02/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wiluna Orongan-CaregiverTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a case management health check inspection, approximately 9:00am on 2/7/23, and met with Wiluna Orongan, caregiver. LPA observed two(2) other caregivers on duty, Lemuel June Orongan, and Micah Orongan, Staff contacted the Licensee Marilyn Green regarding LPA's arrival. Licensee arrived to the facility to meet with the LPA. Abigail Francia arrived to meet with the LPA, Abigail is the newly hired Administrator.

This case management inspection is to conduct a health and safety check, and ensure there is staffing on-site.

LPA reviewed resident files, and obtained copies from the Licensee. LPA obtained updated staffing information from the Licensee; The staff have changed since last inspection on 2/1/23. Licensee agreed to submit to the Department, an updated LIC500 personnel report, due on 2/7/23, no later than 2pm.

LPA observed the residents in care at the facility; Some residents were in their bedrooms, napping and/or watching television, and others were observed in the common areas of the facility. LPA observed the facility was at a comfortable temperature. The facility was observed to have cable television, phone services, PG&E services, all utilities were observed to be on during the inspection. The LPA observed a sufficient supply of food items for residents meals and snacks; Facility had a sufficient supply of cleaners, hygiene products, and paper products. Personal Protective Equipment (PPE) was observed to be sufficient during the inspection.
Licensee agrees, as required, to contact the Department if there are any changes to the above.
Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ST. MICHAEL ASSISTED LIVING 2
FACILITY NUMBER: 496804057
VISIT DATE: 02/07/2023
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During the LPA's inspection, it was observed and identified that the three staff working, and the staff that arrived on premises later during the inspection, all were not associated due to not having the proper/required Identification documents per law.This deficiency is being cited, 87555(c) Criminal Record Clearance, see LIC809D. Civil Penalty will be assessed, see LIC421BG.

During the inspection the LPA observed medications on a bed cart in resident's (R1's) room. Per file review, there is no documentation regarding the handling of medications by the resident. LPA had the Licensee remove all medications and centrally store them. All medications are to be centrally stored and locked securely per regulations. This deficiency will be cited, 87465(h)(1)(2) Incidental Medical & Dental Care, see LIC809D.

Per file review of records, R1 lacked a completed Medical Assessment as required by regulations. This deficiency will be cited, 87458(a) Medical Assessment, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Licensee Marilyn Green. Appeal Rights Provided.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2023 01:09 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/07/2023 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ST. MICHAEL ASSISTED LIVING 2
FACILITY NUMBER: 496804057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited
CCR
87555(c)

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87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:
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Licensee to ensure that individuals hired are criminally record cleared and able to be associated by having the required Identiication documentation. Without valid identification an individual is not able
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This requirement was not met as evidenced by: LPAs interviews, and review of records, and running a fingerprint record search in the Guardian website. S1, S2, S3 and 4, are not associated to the facility as required.The individuals don't have required Identification documentation. This is an immedicate health & safety and/or personal rights risk to residents in care. Civil Penatly assessed for $800.see LIC421BG
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to be associated. Ensure individuals have required identification documentation. Submit plan of correction, including updated LIC500 with staff that are/can be associated as required.POC due 2/8/2023.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2023 01:09 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/07/2023 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ST. MICHAEL ASSISTED LIVING 2
FACILITY NUMBER: 496804057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited
CCR
87465(h)(1)(2)

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Incidental Medical & Denatal Care (h)(1)(2) The following requirements shall apply to medications which are centrally stored:(1) Medications shall be centrally stored: Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.(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.
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Licensee to ensure all medications are centrally stored and locked as required by regulations. Licensee to ensure all medications are inaccessible to all residents in care. Ensuring only the staff trained to handle medications have access to them.
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This requirement was not met as evidenced by: LPA observed medications on a bedside rolling tray table in residents (R1's) room. No documents on file for resident to handle own medications. Medications were accessible to residents in care. This is a risk to personal rights and/or Health and Safety of residents in care.
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Licensee to submit plan of correction, and how the facility will maintain compliance with this regulation. POC due 2/8/23.
Type B
02/15/2023
Section Cited
CCR87458(a)

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Medical Assessment 87458(a) (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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Licensee to ensure that a completed medical assessment is obtained on resident (R1) and a review of the assessment is done and R1's care plan is updated as
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This requirement was not met as evidenced by: Per file review by the LPA, R1 lacked a complete medical assessment as required per regulations. This is a risk to Health and Safety and/or personal rights to residents in care.
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needed regarding care needs and medication assistance. POC due 2/15/23.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
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