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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800848
Report Date: 06/15/2021
Date Signed: 06/16/2021 09:49:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ST. FRANCIS ASSISTED LIVINGFACILITY NUMBER:
496800848
ADMINISTRATOR:MERCADO, JEREZFACILITY TYPE:
740
ADDRESS:1637 JOAN DRIVETELEPHONE:
(707) 789-9260
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
06/15/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rose Wilbor - LicenseeTIME COMPLETED:
12:30 PM
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On June 15, 2021 Licensing Program Manager (LPM) Bethany Moelleers, Licensing Program Analyst (LPA) Carla Fernandes-Goes met with Licensee Rose Wilbor, Administrator Jeremy & Jerez Mercado virtually due to COVID-19.
This virtual Office Meeting is being conducted to discuss facility change of ownership, liability insurance, and change of administrator Jerez Mercado. Department learned on June 7, 2021 that facility has a liability insurance that covers only $250,000 for each occurrence and $750,000 for aggregate. As per H&S Code 1569.605 “
all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.” In addition, the Department learned that facility will have a change of ownership.
As per facility licensee Rose Wilbor and administrators, documentation for new LLC has been filled and application for new license is ready. Facility has pending approval of exemption from Guardian. The Regional Office explained that facility is in non-compliance at this time and expects new application to be filled with Application Unit by July 1, 2021.
In addition, at this time facility St. Francis (Joan St) has as an administrator Jerez Mercado who has a pending exemption from Guardian. As per licensee Rose Wilbor, she will be submitting documentation to change administrator to Jeremy Mercado.

Department is requesting that facility will submit by Friday June 18, 2021 documentation needed for change of administrator at St. Francis (Joan St) and by July 1, 2021 new facility application for St. Francis and St. Francis 2.
There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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