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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801999
Report Date: 03/16/2022
Date Signed: 04/05/2022 01:31:05 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
03/01/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20220301105417
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: 34DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Med Tech, Francisco PreciadoTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
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9
Sexual Assault
INVESTIGATION FINDINGS:
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13
**Amended Report**

Licensing Program Analyst (LPA) Farhaan Sarangi arrived at Saint Michaels Extended Care for the purpose of delivering complaint findings on a report dated for March 16, 2022. LPA was met at the door by Med Tech, Francisco Preciado and was granted access into the facility.

During the complaint investigation, LPA interviewed staff, residents, and various outside parties. In addition, LPA reviewed Client records.

The complaint alleges that Personal Rights were violated. LPA interviewed identified staff members, various outside parties, Resident #1 (R1) and Resident #2 (R2). Based on the interviews that were conducted and the information received, there was inconsistent information during interviewing. In addition, LPA found no evidence to support that Personal Rights were violated. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20220301105417
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: SAINT MICHAEL'S EXTENDED CARE
FACILITY NUMBER: 216801999
VISIT DATE: 03/16/2022
NARRATIVE
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**Amended Report continued**

Based on the statements received, observations made, and documents reviewed, A finding that the complaint allegation of Personal Rights is UNSUBSTANTIATED meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred. Exit interview was conducted and a copy of this report was signed and emailed to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2