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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804171
Report Date: 07/25/2024
Date Signed: 07/25/2024 10:41:09 AM

Document Has Been Signed on 07/25/2024 10:41 AM - 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: 4DATE:
07/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Teddy Rico-House-ApplicantTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA), Alviso conducted a case management to continue the pre-licensing inspection, at approximately 9:00am on 7/25/24, and met with Applicant Teddy Rico. This application is a change of ownership, the facility is currently licensed as St.Michael Assisted Living 2 - #496804057; Teddy Rico is the facility's House Manager. Component III orientation has been completed with applicant Teddy Rico.

Applicant has an approved dementia plan of operation. Applicant has a hospice waiver approval for two (2) residents. Applicant has an infection control plan and emergency disaster plan. Fire clearance is approved for six (6) non-ambulatory only- effective . 10/4/23. The facility has a staff room for three live-in caregivers.

The new Administrator for the facility is Florifess C. Hunt, who is working at the facility Monday through Friday, business days and hours. Ms. Astrid Morancil is no longer the Administrator of the facility as of 6/7/2024, per current Licensee Marilyn Green. Ms. Morancil was not able to work business days and hours on-site at the facility.

Per applicant Teddy Rico, the Administrator for his license will be Florifess C. Hunt. Applicant Teddy Rico stated their understanding of the Administrator to be on-site Monday through Friday, business days and hours, to ensure the facility's plan of operation is in compliance with regulation.
Applicant will update the LIC500 personnel report, for St. Michael's In-Home Care #496804171, to show current sufficient staffing, including the new Administrator (days and hours working on-site).
Applicant will submit an updated emergency disaster plan and an updated infection control plan.

The LPA toured the facility with applicant Teddy Rico. All required corrections have been completed. Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this inspection. LPA will submit a copy of the report to the application unit; The application Analyst will notify the applicant of the application status.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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