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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209600
Report Date: 09/09/2026
Date Signed: 09/09/2026 05:57:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2026 05:57 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ST MICHAEL ASSISTED LIVINGFACILITY NUMBER:
547209600
ADMINISTRATOR/
DIRECTOR:		KUMAR,HARMESHFACILITY TYPE:
740
ADDRESS:550 N LILLIE AVETELEPHONE:
(505) 607-1920
CITY:DINUBASTATE: CAZIP CODE:
93618
CAPACITY: 49CENSUS: 24DATE:
09/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Licensee Harmesh Kumar and Administrator Sabrina KaurTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) K. Kaur arrived for an unannounced annual inspection. LPA was allowed entry by staff and met with Licensee Harmesh Kumar and Administrator Sabrina Kaur.

LPA toured facility with Licensee and Administrator. All pathways, entrances and exits were clear from obstructions. Common rooms have adequate furnishings and lighting. All of the resident bedrooms have all the required furnishings and adequate lighting. Bathrooms have grab bars/skid mats. LPA observed in room #17, flooring near resident’s bed that is lifting. LPA observed oxygen in use without signage. Several window screens throughout the facility observed to have small tears, Room 15 Bathroom window was missing a screen. Facility refrigerator/freezer temperatures observed with range. LPA observed a 2-day supply of perishable foods. LPA observed a supply of extra bed linens and personal hygiene and grooming products in storage room. Cleaning supplies are stored in a locked closet in the laundry room. Medications are locked in a medication room. First aid kit contains all the required items. A fire extinguisher is present and has a service date of 03/13/2026. Smoke detectors and carbon monoxide were operating. Fire Alarm was inspected by a third party on 04/06/2026. Facility has a call light system, which is operating properly. Outside of the facility toured. No outside hazards were observed. Fire Drill was conducted on 8/10/2026. Resident’s files were reviewed to have signed Admission Agreement, Personal Rights, and Emergency Identifications forms and medical assessments. Staff files reviewed and have the required documentation. Surety bond was reviewed. Liability Insurance policy effective 10/20/25 to 10/20/2026. Medication review conducted revealed two out of four residents’ medication was not administered as prescribed.



Deficiencies cited per California Code of Regulations, Title 22, on the attached 809D.
Alexandria Walton
Kamaldeep Kaur
DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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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Document Has Been Signed on 09/09/2026 05:57 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/09/2026 at 01:24 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ST MICHAEL ASSISTED LIVING
FACILITY NUMBER: 547209600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2026
Section Cited
CCR
87618(b)(3)(B)

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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
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Administrator agrees to have signs posted in appropriate areas. Verification will be sent to the Dept by POC due date.
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Based on observation, interview, and record review, the facility did not comply with the regulation listed above due to R1 not having a "Oxygen in Use Sign" posted, which poses a potential health and safety risk to residents in care.
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Type B
09/23/2026
Section Cited
CCR87303(c)

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87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
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Administrator agrees to replace/ repair window screens and submit receipts/ pictures by due date
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Based on observation, the facility did not comply with the regulation listed above due to several window screens throughout the facility observed to have small tears, Room 15 Bathroom window was missing a screen, which poses a potential health and safety risk to residents in care.

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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.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/09/2026 05:57 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/09/2026 at 02:55 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ST MICHAEL ASSISTED LIVING
FACILITY NUMBER: 547209600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2026
Section Cited
HSC
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Administrator agrees to submit statement of intent by due date to review process to implement to avoid future error and provide in-service training to staff and submit records when completed.
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Based on observation, interview, and record review two out of four residents’ medication was not administered as prescribed. R2’s Docusate 100 MG started on 8/17/2026 to 9/9/2026 should have 24 pills given from Qty 30. Bubble pack has 4 remaining, which means 26 were given. R3’s Trazodone HCL 50 has a start of 8/31/2026 for PRN and routine medication. 08/31/2026 – 9/9/2026 should have 10 given for routine and PRN log shows 6 pills given total of 16. Qty 60 – 16 = 44 should be remaining and bubble pack has 47 remaining which poses an Immediate health and safety risk to residents in care.
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Type B
09/23/2026
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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Administrator agrees to repair and submit invoices, receipts, and pictures of repairs by due date.
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Based on observation, and interview, the facility did not comply with the regulation listed above due to Room 18 observed with sink faucet that splashes water outside of the sink, Room 17 has flooring that is lifted, transition strip missing in common room which poses a potential health and safety risk to residents in care.
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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.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ST MICHAEL ASSISTED LIVING
FACILITY NUMBER: 547209600
VISIT DATE: 09/09/2026
NARRATIVE
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LPA requested the following documents to be submitted to CCL by 09/16/2026: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview completed with Licensee, Harmesh Kumar and Administrator Sabrina Kaur. Plans of corrections were developed by Licensee and reviewed by Administrator and LPA. A copy of this report, deficiencies and appeal rights have been provided to Licensee, whose signature on this form confirms receipt of this document.
NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Kamaldeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
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