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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800848
Report Date: 02/24/2022
Date Signed: 02/24/2022 12:42:10 PM


Document Has Been Signed on 02/24/2022 12:42 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
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:
02/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator - Jeremy MercadoTIME COMPLETED:
12:42 PM
NARRATIVE
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 On 2/24/2022 Licensing Program Analysts (LPA) Hansen conducted an unannounced case management visit to this facility and met with administrator Jeremy Mercado with Licensee Rose Wilbor and Administrator George Wilbor on speaker phone. This case management is being conducted due to facility liability insurance being in non-compliance with Department Health & Safety Code # 1569.605. Facility census at this time is 5.

Facility submitted on 6/7/2021 a copy of Liability Insurance Certificated that covers only $250,000 for each occurrence and $750,000 for aggregate. Per Health & Safety 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.
Department has requested licensee Rose Wilbor to submit proof of liability insurance according with Health & Safety code by July 12, 2021. Facility was cited on 7/16/2021 for the same Health & Safety Code mentioned above. Deficiency wasn’t cleared and at this time facility doesn’t have a liability insurance according with Health & Safety Code # 1569.605. (see copy, LIC 809-D)

It is your responsibility to continue to assess the needs of your residents in care and determine if your staffing needs to be increased based on the residents care needs. If you identify at any point that 2 staff on shift is not sufficient you will need to increase staffing and provide an updated LIC500.

Appeal of Rights Given.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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 02/24/2022 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 496800848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/03/2022
Section Cited

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H&S1569.605 - Liability Insurance:Based on review and interview the licensee did not comply with the section cited above 1 of 1 facility liability insurance which poses a potential health, safety or
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personal rights risk to persons in care.
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with H&S Code # 1569.605 and submit a copy to the CCLD by due date of 03/03/2022.

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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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