Saint Michael Residential Home

Type of visit: Required - 1 Year

On 3/11/2026 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 is licensed with capacity for 6 residents and currently has 5 residents who are 60 and over with neurocognitive disorder. 5 may be non-ambulatory and 1 may be bedridden in room #5 and 1 hospice waiver. LPA observed 5 out of 5 residents at the facility and 2 staff. 3 Out of 5 residents were having breakfast in their bedroom and 2 out of 5 was at the dining room. 2 Out of 2 staff were attending to the needs of the residents. Upon entry, LPA observed emergency disaster plan for RCFE (LIC 610E), postings of personal rights, nondiscrimination notice, compliant information, Long-Term Care Ombudsman (LTCO), and sample of the meal menu. 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 are 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 with a digital thermometer at 108.8 degrees F. page 1 of 2 See LIC 809C Fire extinguisher was last inspected on 07/16/2025. The facility is equipped with wall fire alarm system, carbon monoxide and smoke detectors and were observed to be in good working condition. No smoking signs were posted on on the walls, "oxygen in use" sign was observed posted conspicuously. LPA observed facility first aid kit were complete and were accessible to staff. LPA reviewed 3 out of 5 resident record and 2 staff record and found them to be complete and up to date. Disaster training was administered on 01/01/2026 and 01/04/2026 (fire, disaster & earthquake). Staff has valid certificate for 1st/aid CPR, continuing education training, criminal background and fingerprint cleared and records are up to date and complete. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with LIC/Administrator Debbie Aguilar. A copy of the report was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Mar 11, 2026

Type of visit: Case Management - Other

on 07/25/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced case management visit. LPA announced the purpose of the visit and met with Debbie Aguilar, Administrator (ADM). LPA observed 5 resident and 2 staff. During visit LPA toured the facility and observed 5 resident bedroom. LPA observed 1 resident bathroom and 1 staff room. During visit LPA reviewed 3 staff files and LPA verified fire clearance was approved on 06/10/25. No deficiencies were cited at this time as per California Code of Regulations Title 22. Technical Violation was given please see (LIC 9102) This report was reviewed with Administrator (ADM) Debbie Aguilar and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 25, 2025

Type of visit: Required - 1 Year

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 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. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Apr 8, 2025

Allegation investigated: Resident sustained severe burns while in care due to lack of care from staff

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver the complaint investigation findings, met with Administrator (ADM) Debbie Aguilar and stated the purpose of the visit. On 4/15/2024 The department received a complaint alleging that the resident sustained severe burns while in care due to lack of care from staff. On 4/17/2024 - LPA Simi Rai conducted the initial investigation. LPA Rai requested and verified the documents received on the initial case management visit on 4/15/2024. page 1 of 3, see LIC 9099C Unsubstantiated On 4/11/2024 the Department received an incident report regarding a resident who (R1) who set toilet paper on fire while in the bathroom, that caused third and fourth degree burns to R1s feet and legs that resulted to R1s demise. The department conducted interviwe with 2 staff(S1, S2), 4 residents (R2 to R5), 2 responsible parties (RP1, RP2), LIC/ADM, and 2 case managers (CM1 and CM2). On 4/17/2024 S1 stated he/she heard the fire alarm. When he/she arrived at R1s bedroom S2 was already pulling R1 out of the bathroom and S1 poured water on the wall that caught on fire. S2 stated that residents are regularly checked between chores, and he/she checks "countless of times, even in the middle of the night." LIC/ADM stated he/she did not see any lighter or cigarette near R1s room and does not know how R1 started the fire. LIC/ADM stated when R1 has cigarettes or a lighter, R1 would give those to staff to be put away in a locked drawer. LIC/ADM stated that R1 would listen to staff. On 4/17/2024 R2 stated that staff treats residents very nicely and sees nothing unsafe at the facility. R3 stated S2 turned off the oxygen tank and took R4 to safety and then dealt with the fire and R1. R4 stated that residents are not allowed to have a lighter but can get a lighter from staff. On 4/17/2024 RP1 stated he/she has not noticed anything unsafe about the facility. No lighters or fire type products lying around. If someone smokes, they smoke outside. On 5/1/2024, the department conducted an interview with case manager 1(CM1), who stated that R1 "has a history of lighting things on fire at a different care home, and does not believe that the staff were aware of the previous fire incident." On 5/1/2024, the department conducted an interview with RP2. RP2 stated that R1 was known to smoke frequently. RP2 stated that R1 was happy at the facility. RP2 stated he/she did not tell LIC/ADM and staff that R1 has prior history of lighting things on fire. page 2 of 3 see LIC 9099C Based on document review, R1 had different case managers. R1 did not express self-harm or suicidal tendencies, no safety issues or access to weapons were identified, no signs of depression and only goes out to smoke cigarettes. On 7/8/2024 a follow up interview was conducted with LIC/ADM who stated, the doors of resident's room are always open. Residents are checked on frequently as staff move through the house. Staff are able to hear the clients when they call because it is a small house. On 7/9/2024 a follow up interview was conducted with S2, who stated there is no schedule or documentation of how often they check on residents, they typically check on clients approximately every 30 minutes. On 7/23/2024, the department interviewed R1s prior case manager (CM2) who stated that he/she is aware that R1 had a history of lighting things on fire. CM2 stated that current facility staff is aware R1 should not have a lighter and assumed staff knew the reason why R1 is not supposed to have a lighter. The facility is strict about allowing R1 to have a lighter. Based on document review, the report stated, paramedics who responded to the facility didn’t notice anything that did not line up with the incident as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit based on California Code of Regulations Title 22. An exit interview was conducted with licensee/administrator Debbie Aguilar, and a copy of the report was provided. Page 3 of 3 end of reportthe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 26-AS-20240415134707

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Apr 17, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit and met with Administrator (ADM) Debbie Aguilar. LPA Rai stated the purpose of the visit and conducted a health and safety check at the facility. On April 12, 2024, the Department received an in incident report stating resident, R1 sustained burn injuries after a fire incident at the facility. R1 was transported to the hospital via ambulance. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed construction materials in the backyard. Staff (S1) stated they replaced the flooring in the resident bathroom and the materials will be disposed this afternoon. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. During the tour of the kitchen, LPA Rai observed a cabinet with locking capability which is where the facility staff lock the sharps, such as knives. LPA Rai observed the cabinet unlocked during the visit. LPA Rai observed the kitchen was not being used by staff to prepare food and no staff were observed in the kitchen. Staff S1 locked the cabinet during visit. During the tour of the laundry room, LPA Rai observed a cabinet with locking capability which is where the facility staff lock the chemical solutions, such as laundry detergents. LPA Rai observed the cabinet unlocked during the visit. LPA Rai observed the laundry room was not being used by staff and no staff were observed in the laundry room. Staff S1 locked the cabinet during visit. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. 1 Out of 5 resident bedrooms (Bedroom #2) was occupied by a bedridden resident. LPA Rai observed the exit door located in Bedroom #2 was blocked by recliner chair and the exit door was not accessible. Staff S1 was not able to move the recliner chair as it was extended to lay flat and required a remote to adjust the setting as it was an electric powered recliner. S1 was able bring down the foot rest of the recliner but the passageway was still not clear. ADM stated they will talk to the family and ensure the passageway to the exit door is clear. LPA Rai toured the dining room and observed the medication cabinet. LPA Rai observed the cabinet door had locking capabilities but it was unlocked during visit. LPA Rai observed the staff were not administering medications. Administrator locked the medication cabinet during visit. LPA Rai observed no smoking signs posted around the facility and 1 out of 5 residents observed using oxygen in the facility. LPA Rai was not able to observe Bedroom #1. Staff S1 stated the resident R2 prefers to lock the room and staff are not able to access the bedroom and was not able to verbalize how staff would be able assist R2 in an emergency. ADM stated they will submit a plan of action to ensure the health and safety of the resident R2. LPA Rai obtained the following documents: R1's Physician's Report dated 10/21/2023, R1's Appraisal/Needs and Services dated 7/24/2023, R1's Centrally Stored Medication Log and Medication Administration Record (MAR) from July 2023 to April 2024, R1's Admission Agreement, R1's Functional Capabilities Assessment dated 7/25/2023, and R1's After Visit Summary 7/25/2023 and 11/7/2023. This case management will be kept open pending investigation. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator (ADM) Debbie Aguilar and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Apr 16, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by: Based on interview and observation, LPA Rai observed the cabinet containing knives was unlocked and accessible to residents with dementia which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Licensee/Administrator agreed and understood. Staff S1 locked the cabinet during today's visit

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Apr 16, 2024

87705 (f) (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by: Based on interview and observation, LPA Rai observed the cabinet containing laundry detergent was unlocked and accessible to residents with dementia which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Administrator agreed and understood. Staff S1 locked the cabinet during today's visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Apr 16, 2024

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on interview and observation, LPA Rai observed the area infront of the exit door for a bedridden resident on Hospice services was obstructed by a recliner chair which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Apr 16, 2024

87465 Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Based on interview and observation, LPA Rai observed the medication cabinet containing the centrally stored medication was unlocked and accessible to persons other than employees and residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to train staff by POC due date. Licensee/Administrator agreed and understood. Administrator locked the cabinet during today's visit

Type of visit: Required - 1 Year

On 3/25/2024 Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Annual required inspection at facility and met with caregivers/designated administrators Joselito Garcia (S1) and Nancy Esteban (S2). Administrator (ADM) Debbie Aguilar is currently out of the country at the time of this visit. LPA accompanied by S1 toured the exterior, and interior of the facility including, but not limited to the following areas, 5 resident bedroom, and 1 staff room, 2 bathrooms, the kitchen, dining, living room and activity area. The facility's room temperature was 73 degree F. LPA inspected the exterior and walkways and pathways were free from obstruction. LPA inspected the kitchen observed, knives were safe and secure in a locked cabinet. LPA inspected the refrigerator and freezer, and observed 2 days' supply of perishable foods, an the pantry has 7 days supply of nonperishable food. LPA observed chemicals, laundry detergents and cleaning supplies are in a separate area and not accessible, water temperature in the kitchen sink is at 105 degree F. LPA observed both staff are attending to the residents' needs, after breakfast, the bedrooms and bathrooms were inspected, all residents' bedrooms were observed free of odor. Beds have pillows, top and bottom sheets, waterproof protectors and blankets. Working light fixtures were observed in all rooms. Bathrooms are equipped with non-slip mats, safety grab bars and shower chairs. Hot water temperature was 105 degree F. page 1 continued to page 2 LIC 809C The facility has a wired fire alarm and also has a carbon monoxide detector and a fire extinguisher was last inspected on 05/10/2023. LPA randomly selected 3 resident file record for review and observed 3 out of 3 centrally stored medication record (CSM) are up to date. 3 out of 3 residents have current Appraisal/Needs and Services Plans (ANS) on file. A copy of their Admission Agreement and Personal Rights were also on file. 3 out of 3 residents are missing the Consent Forms, and Weight Record, 1 out of 3 resident file record does not have TB test result documented. S1 and S2 stated, they are both new in the facility and have been working for less than 6 months and is not aware of where the other records are filed. S1 has been in the facility for 4 months, and S2 has been in the facility for 1 month. LPA reviewed facility record and found that the facility disaster preparedness training is up to date. All staff have criminal background clearance from Community Care Licensing and are listed in the facility's personnel roster. Current first aid certification and training for types of residents served were verified. During today's visit, a citation is issued per California Code of Regulation, Title 22. An exit interview was conducted with S1 Joselito Garcia, and S2 Nancy Esteban, the designated ADM for the facility in the absence of administrtor Debbie Aguilar. A copy of the signed report and appeals rights was provided. End of Report page 2 of 2the state’s words, verbatim · CDSS document, Mar 25, 2024