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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202339
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:34:14 PM

Document Has Been Signed on 04/17/2024 12:34 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SAINT MICHAEL RESIDENTIAL HOMEFACILITY NUMBER:
435202339
ADMINISTRATOR/
DIRECTOR:		AGUILAR, DEBBIE R.FACILITY TYPE:
740
ADDRESS:86 CASHEW BLOSSOM DR.TELEPHONE:
(408) 623-4832
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
04/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Administrator, Debbie AguilarTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the Type A deficiencies cited on 4/15/2024. LPA Rai met with Administrator (ADM) Debbie Aguilar and stated the purpose of today's visit.

During visit, LPA Rai toured the facility with staff (S1). LPA Rai observed the cabinets containing knives, laundry detergent and medications were locked and inaccessible for residents. LPA Rai observed all exits were cleared of obstruction, especially the passageway exit in Bedroom #2.

LPA Rai reviewed the Plan of Correction (POC) submitted by Administrator (ADM) Debbie Aguilar on 4/15/2024. ADM conducted an in-service training to staff on 4/15/2024 on the regulations cited.

Based on today's inspection visit, the Administrator and staff have corrected all of the above citation/deficiencies. Plan of Correction (POC) clearance is issued and provided to ADM.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator (ADM) Debbie Aguilar and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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