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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801999
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:57:10 PM

Document Has Been Signed on 05/16/2023 02:57 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: 32DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator, Rufus Zingkhai, and Staff Member, Francisco Preciado TIME COMPLETED:
03:10 PM
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At approximately 1:50PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit and met with Staff Member, Francisco Preciado. Administrator, Rufus Zinghkai, arrived later during visit at approximately 2:10PM. The Facility serves residents with Dementia and has a plan of operation for dementia care and programming on file. Facility is a two story building and has an approved fire clearance for 44 non-ambulatory residents and an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there are currently 32 residents in care, and 4 staff members on shift.

At approximately 2:15PM, LPA reviewed the staff roster with Administrator and found that the four staff members on-site were associated to the facility per regulation. At approximately 2:30PM, LPA conducted a walk-through of the facility. LPA observed that the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip mats were present. Bathrooms were supplied with paper towels, liquid hand soap, and hand-washing signs. Toxins were secure and inaccessible to clients in care. There was a sufficient supply of hygiene products, paper products, and linens available for client use. The amount of fresh and non-perishable foods available was within regulation.

Fire Extinguishers were last inspected March 2023.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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