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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800848
Report Date: 03/10/2022
Date Signed: 03/10/2022 08:59:42 AM

Document Has Been Signed on 03/10/2022 08:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ST. FRANCIS ASSISTED LIVINGFACILITY NUMBER:
496800848
ADMINISTRATOR:MERCADO, JEREMYFACILITY TYPE:
740
ADDRESS:1637 JOAN DRIVETELEPHONE:
(707) 789-9260
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Jeremy Mercado - AdministratorTIME COMPLETED:
09:00 AM
NARRATIVE
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On 3/10/2022 at approximately 9:00 AM licensing Program Analyst (LPA) Hansen arrived unannounced and met with Jeremy Mercado-Administrator regarding uncleared citations pertaining to liability insurance and administration qualification and duties.

Administrator was unable to provide proof of liability insurance per health and safety code section 1569.605. A citation was originally cited by LPA Fernandez-Goes on 7/16/2021 while conducting a required 1 year annual inspection, POC date was 7/30/2021 and facility failed to clear this citation. LPA Hansen reissued a citation HSC Section 1569.605 on 2/24/2022, with a POC date of 3/3/2022 and facility has failed to clear this citation. Due to failure to clear citation and obtain liability insurance per regulation civil penalties are being issued today in the amount of $600.00 ($100. per day from 3/4/2022 - 3/9/2022). Administrator was informed that civil penalties may accrue of $100 per day until citation is cleared.

Facility failed to correct citation 87405(d)(2), Administrator qualification and duties issued on 2/24/2022 as a result of a complaint investigation. Facility continues to be in violation of regulation and noncompliant in clearing deficiencies per agreed upon Plan of Correction date of 2/25/2022. An updated LIC 500 was submitted to the Department indicating current administrator Jeremy Mercado and George Wilber “Administrator/Maintenance”. Jeremy Mercado agrees to work with co-administrator George Wilber to clear citation re-issued during todays visit.

Civil Penalties are being assessed in the amount of $600 due to not having liability insurance according to requirements.

The following deficiencies were observed (see LIC 809D) and 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 and appeal of rights provided.

809D: issuing citation again.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 08:59 AM - It Cannot Be Edited


Created By: Shannan Hansen On 03/09/2022 at 02:44 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. FRANCIS ASSISTED LIVING
FACILITY NUMBER: 496800848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited

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87405(d)(2) Administrator Qualificaitons and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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This requirement is not met as evidence by:
Based on LPAs observations the facility is not screening staff and visitors.
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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