St. Michael's In-Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stevenson arrived to conduct a a required -1 year inspection, at approximately 12:30pm and met with Licensee Teddy Rico. There are currently five (5) residents in care. Facility has Fire clearance for six (6) non-ambulatory only residents. Facility has a hospice waiver for Three (3) Residents. The facility has a staff room for three live-in caregivers. The facility does have emergency food/water and emergency supplies to meet the "72 hour shelter in place" requirements. Facility has an approved dementia plan of operation. Facility has a required infection control plan and emergency disaster plan. Hot water was measured at 111.7 degrees Fahrenheit. LPA observed a sufficient and varied supply of food, perishable and non-perishable, for resident meals/snacks. Facility had sufficient furnishings for residents in care. The facility has sufficient lighting in all rooms, bathrooms, and common areas, including night and emergency lights. There was a sufficient supply of hygiene products, linens, cleaning supplies, and paper products for use as needed. All exits were free and clear of obstruction. Fire extinguisher was charged, in the green area, tag expired 10/2025 and will need to re-inspected. The facility was at a comfortable temperature for residents; Residents were observed to be watching television, listening to music, and engaging with the staff. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed; Facility has a sufficient supply of personal protective equipment(PPE). Continued on LIC809C.. Continued from LIC809 Cleaning supplies and pesticide sprays are kept under the kitchen sink and LPA noted that a latch lock only worked intermittently. A Technical Advisory of 87309(a)(2) was issued which requires toxins and dangerous items to be locked and licensee is asked to replaced the lock(s) right away to ensure easier compliance. LPA reviewed five (5) resident files and three (3) of five (5) were missing complete records and a Type B deficiency is levied for CCR 87506 (a) which requires a complete record for each resident is kept on site. LPA reviewed five (5) staff files and all 5 have required documents. Facility knows to conduct and Emergency/Disaster drill every 3 months with the last one conducted 05/15/2026 Medicines were found centrally locked and secure, facility maintains an Medication Administration Record. LPA is requesting the following documents be updated and submitted by 10/15/26 LIC308 - Any Updated Designation of Administrator Responsibility LIC500 - Personnel Report LIC9020 - Resident Roster LIC610E- Emergency Disaster Plan (Review and update as needed/required) Submit if any changes. Copy of Current Liability Insurance Evidence of Licensing Fees having been paid Updated Lease Agreement Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee Teddy Rico and appeal rights were given.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 25, 2026

Resident Records 87506(a) The licensee shall ensure that a seperate, complee and current record is maintained for each resident in the facility...readily available to facility staff and to the licensing agency staff.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee to self-certify they have read regulations contained in CCR 87506 and to submit copies or Physician's Report and Evidence of Negative TB test for S2 and to submit an Admission's agreement for S3 by end of business day 09/25/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Alviso conducted a required -1 year inspection, at approximately 2:25pm 8/6/2025, and met with Licensee Teddy Rico. There are currently six (6) residents in care. Fire clearance is approved for six (6) non-ambulatory only. The facility has a staff room for three live-in caregivers. The facility's last emergency disaster drill was conducted on 5/18/2025. The facility does have emergency food/water and emergency supplies to meet the "72 hour shelter in place" requirements. Facility has an approved dementia plan of operation. Facility has a hospice waiver approval for two (2) residents. Facility has a required infection control plan and emergency disaster plan. LPA reviewed six (6) resident files. All files were complete. LPA reviewed five (5) staff files. All staff had criminal record clearance as required. LPA reviewed staff annual training. Staff S2 & S3 have first aid certification and CPR certification. Hot water was measured at 111.7 degrees Fahrenheit. LPA observed sufficient supply of food, perishable and non-perishable, for resident meals/snacks. Facility had sufficient furnishings for residents in care. The facility has sufficient lighting in all rooms, bathrooms, and common areas, including night lights. There was a sufficient supply of hygiene products, linens, cleaning supplies, and paper products for use as needed. All exits were free and clear of obstruction. Fire extinguisher was charged, in the green area, tag expires 10/2025. The facility was at a comfortable temperature for residents; Residents were observed to be watching television, listening to music, and engaging with the staff. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed; Facility has a sufficient supply of personal protective equipment(PPE). All medications were stored, locked up, and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care. The backyard has a shade covered sitting area for residents in care. Continued on LIC809C.. LPA is requesting the following documents be updated and submitted by 9/6/25 LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Submit if any changes. Infection Control Plan- (ensure to review and update as needed/required) Submit if any changes. Copy of LIC400 Handling of Client Cash Resources-complete & submit Copy of Surety Bond- if handling cash Copy of Current Liability Insurance Resident Roster Copy of current Administrator Certificate Following deficiencies that will be cited, see LIC809D: Per LPA review of records, there was no proof of staff, S2 and S3, having obtained required annual medication training. Deficiency cited, HSC 1569.69 (b) -Employees assisting residents with self-administration of medication; training requirements. Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. Per LPA review of records, there was no proof of staff, S2 and S3, having obtained required annual direct care staff training. Deficiency cited, HSC 1569.625(b)(2) Staff training; legislative findings; contents - In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee Teddy Rico. Appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Jul 25, 2024

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, May 28, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 5 COMP II Participants: Morancil, Astrid (Administrator); Hunt, Florifess (Licensee) & Rico, Teddy (Licensee) Interview Method: Virtual interview (MS Teams) On 5/10/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 10, 2024