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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804171
Report Date: 09/15/2026
Date Signed: 09/15/2026 04:05:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/15/2026 04:05 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:		HUNT, FLORIFESSFACILITY TYPE:
740
ADDRESS:7300 BURTON AVETELEPHONE:
(707) 753-4946
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 5DATE:
09/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Florifess Hunt - LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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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..
Bethany Moellers
Star Stevenson
DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2026
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ST. MICHAEL'S IN-HOME CARE
FACILITY NUMBER: 496804171
VISIT DATE: 09/15/2026
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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.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/15/2026 04:05 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/15/2026 at 03:38 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ST. MICHAEL'S IN-HOME CARE
FACILITY NUMBER: 496804171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87506(a)

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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.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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