435202339-5-2-2025-26-AS-MPAA-DGB5S4-20250502201207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202339
Report Date: 04/08/2025
Date Signed: 05/02/2025 08:13:49 PM

Document Has Been Signed on 05/02/2025 08:13 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 HOME		FACILITY NUMBER:	435202339
ADMINISTRATOR/ DIRECTOR:	AGUILAR, DEBBIE R.		FACILITY TYPE:	740
ADDRESS:	86 CASHEW BLOSSOM DR.		TELEPHONE:	(408) 623-4832
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 6	DATE:	04/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Debbie Aguilar - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/8/2025 Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection. LPA met with Debbie Aguilar LIC/ADM. LPA stated the purpose of the visit. The facility has a current census of 6 residents and serves 60 and over who are elderly and has neurocognitive disorder. 5 may be non-ambulatory and 1 may be bedridden. LPA observed 2 staff at the time of the visit. All residents are present during the time of the visit 6 out of 6 were in their room and resting, 3 out of 6 are non-ambulatory, 1 out of 6 is ambulatory and 2 out of 6 is bedridden. LPA toured the facility inside and outside including the living room, kitchen, dining room, 2 restrooms, 5 resident bedrooms and staff room, backyard and side emergency exits. LPA observed hallways and walkways to be free from obstructions. LPA observed the kitchen, dining, resident bedrooms, and staff room be organized and sanitary, the restrooms are equipped with anti skid mat and grab bars. Residents room has ample storage for their personal belongings. LPA inspected food storage and observed 2 days of perishable and 7 days of nonperishable food supplies. LPA observed the medication, chemicals and knives were locked and not easily accessible to residents. The room temperature is at 70 degrees F, and hot water temperature was measured at 105 degrees F. Fire extinguisher was last inspected on 7/9/2024. The facility is equipped with carbon monoxide and smoke detectors and were observed to be in good working condition when tested. page 1 of 2 See LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAINT MICHAEL RESIDENTIAL HOME	FACILITY NUMBER: 435202339
	VISIT DATE: 04/08/2025

NARRATIVE

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ADM stated that 2 residents are bedridden. LPA discussed with ADM that per fire clearance the facility cannot have more than 1 bedridden resident.

LPA observed 2 staff (S1, S2). S2 have been separated from the facility since on 10/4/2019. ADM submitted a list of Personnel to Community Care Licensing Division (CCLD) on 1/23/2025 and S2 is not listed as a staff. S2 stated that he/she has been an staff for more than 5 years, left the facility when S2s spouse passed away and came back. S2 has clear criminal background on record and have not worked in any other facility. ADM stated S2s spouse passed away and was the one being removed from the record and not S2. ADM associated S2 by submitting the application to Guardian but can no longer be associated due to the fact that S2 has been separated from the facility for more than 5 years.

LPA observed facility first aid kit were complete and were accessible to staff. LPA reviewed 3 out of 6 resident record and 2 staff record and found them to be complete and up to date. Disaster training was administered on 3/1/2025 (fire, disaster & earthquake). Staff training was up to date and complete.

Based on observation and document review, the following deficiencies are cited today based on the California Code of Regulations (CCR) Title 22, 87202(a)(2) for the fire clearance and 87355(e)(2) for S2s criminal background clearance that is no longer valid after 3 years and will require a new livescan. Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department a total of $500.00.

An exit interview was conducted with LIC/Administrator Debbie Aguilar. A copy of the report and appeals rights were provided.

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end of report

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/02/2025 08:13 PM - It Cannot Be Edited

Created By: Maria Partoza On 04/08/2025 at 12:22 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAINT MICHAEL RESIDENTIAL HOME	FACILITY NUMBER: 435202339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons . This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not obtaining an appropriate fire clearance approved by city and county fire department providing fire protection services by accepting 2 bedridden residents. ADM stated R2 & R5 are bedridden. Based on document review the facility is approved for 1 bedridden person in bedroom #5 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	LIC/ADM stated that a request will be submitted to CCLD to increase the amount of bedridden that the facility can accommodate. ADM will submit a memorandum of understanding of CCR Title 22 87202(a)(2).

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee/administartor did not comply with the section cited above by not ensuring S2 has a valid criminal background clearance after prior to working and after separating S2 from the facility on 10/4/2019, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	ADM/LIC stated that S2 will be livescanned today and will email proof of livescan by POC due date. LIC/ADM will submit a memorandum of understanding regarding 87355(e)(2) that all direct staff should have a current and valid criminal background check.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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