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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804171
Report Date: 05/28/2024
Date Signed: 05/28/2024 05:30:19 PM

Document Has Been Signed on 05/28/2024 05:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ST. MICHAEL'S IN-HOME CAREFACILITY NUMBER:
496804171
ADMINISTRATOR/
DIRECTOR:
MORANCIL, ASTRIDFACILITY TYPE:
740
ADDRESS:7300 BURTON AVETELEPHONE:
(707) 799-0789
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 5DATE:
05/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Teddy Rico-House-ApplicantTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection, at approximately 1:30pm 5/28/24, and met with Applicant Teddy Rico. This application is a change of ownership, the facility is currently licensed as St.Michaels Assisted Living 2 - #496804057; Teddy Rico is the facility's House Manager.

The LPA toured the facility with applicant Teddy Rico. The following items were observed, and discussed,

Per staff file reviews, S3 lacked current first aid and CPR certification; S3's first aid/CPR expired 3/5/24. This is a deficiency 87411(c )(1) Personnel Requirements – General. This deficiency will be cited on the facility license number 496804057, see report LIC809D dated 5/28/24.

During physical plant inspection, LPA observed that there are many walls throughout the facility that need to be wiped down/cleaned, and touched up with paint. The hallway bathroom had a broken toilet paper holder on the wall by the toilet. The kitchen needed cleaning, the sink was dirty and needed to be scrubbed clean, the appliances were needing to be wiped down, as well as the stove, LPA observed crumbs, dust, dirt, and grime in the kitchen area. The backyard had some overgrown plants/weeds hanging over into the walkway, the patio furniture was dirty, dusty, and had some spider webs. There were spider webs on the shed, on the shed's top, and in areas around the patio deck. There's a board, could be a few, that was observed to be bulging on the deck which has created a trip hazard. There is a pile of ol wheelchairs and walkers that are dirty and have spider webs on them, on the covered area of the backyard. The covered patio area needs to be cleaned up from dirt and spider webs. This is a deficiency 87303(a) Maintenance and Operation- This deficiency will be cited on the facility license number 496804057, see report LIC809D dated 5/28/24.

The LPA will return to continue a pre-licensing inspection, once deficiencies are corrected on 496804057, current facility license.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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