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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801999
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:30:50 PM

Document Has Been Signed on 04/05/2022 01:30 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:
04/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Med Tech, Francisco PreciadoTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Saint Michael's Extended Care for the purpose of delivering amended complaint investigation findings for an investigation dated for March 1, 2022. LPA was greeted at the door by Med Tech, Francisco Preciado, and granted access into the facility.

LPA delivered the amended complaint investigation findings. No deficiencies were observed or cited during this Case Management-Other 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: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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