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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801999
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:02:15 PM

Document Has Been Signed on 03/10/2022 02:02 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:SAINT MICHAEL'S EXTENDED CAREFACILITY NUMBER:
216801999
ADMINISTRATOR:ZINGKHAI, RUFUSFACILITY TYPE:
740
ADDRESS:416 4TH STREETTELEPHONE:
(415) 453-4600
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 44CENSUS: 35DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Rufus ZingkhaiTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Saint Michael's Extended Care for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Med Tech, Francisco Preciado, and granted access into the facility. Administrator, Rufus Zingkhai arrived 20 minutes later.

LPA toured facility with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on March 2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. There was a sufficient supply of both perishable and non-perishable foods as required by Title 22 Regulations. Food stored in the refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the hallway. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. There was a supply of cleaners, hygiene products and paper products available for residents. Facility double bedroom occupancy have bathrooms for residents which were supplied with community hand towels and hand soap dispensers. Showers were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. First aid kit was appropriately filled. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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: SAINT MICHAEL'S EXTENDED CARE
FACILITY NUMBER: 216801999
VISIT DATE: 03/10/2022
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LPA requested the following licensing documents to be sent to the Regional Office:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
Facility sketch

In addition, LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one on February 3, 2022. N95 Fit testing occurred on October 18, 2021.

No deficiencies were observed or cited during this Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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