496800848-4-26-2022-21-AS-BMOS-CEAMLK-20220510094226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800848
Report Date: 04/26/2022
Date Signed: 04/26/2022 10:45:10 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20220126160751

FACILITY NAME:	ST. FRANCIS ASSISTED LIVING		FACILITY NUMBER:	496800848
ADMINISTRATOR:	MERCADO, JEREMY		FACILITY TYPE:	740
ADDRESS:	1637 JOAN DRIVE		TELEPHONE:	(707) 789-9260
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 4	DATE:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Interim Administrator George Wilbor		TIME COMPLETED:	10:44 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to meet residents care needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Hansen made an unannounced subsequent visit to the facility. The purpose of this visit is to deliver the findings for the above allegation. LPA was welcomed to the facility by staff Norma who called Interim Administrator and showed up 25 minutes later and met to go over complaint findings.

R1 arrived at hospital on 1/19/2022 for COVID related symptoms. Complainant alleges that R1’s care needs are not being met based on R1’s condition upon arrival at hospital. LPA obtained hospital records that state in part; upon arrival a very confused and agitated patient with blackened and crusted lips along with several unblanchable pressure ulcers to sacrum was observed. Additional, hospital records were obtained during the investigation that state R1 has two sacral decub ulcers along with tongue that is blackend, and lips are cracked and dry with some dried blood noted on lips. LPAs interview with medical professional revealed cause and concern of neglect at the facility as R1’s appearance was cachetic (skin and bones) and poor hygiene. LPA conducted interviews with administrator, facility staff and reviewed records that revealed facility failed to observe R1s change of condition and developing pressure injuries.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 21-AS-20220126160751

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Administrator was unable to provide LPA proof that R1s Primary Care Provider (PCP) was notified of R1s change of condition. LPA confirmed R1 was not receiving home health care for pressure injuries. Staff (S1) reported not seeing any wounds or pressure injuries on R1 stating R1 “had good skin”. LPA obtained a photo of R1’s coccyx area at time of arrival to hospital which is conflicting with S1’s interview statement. R1 was discharged from hospital on 1/26/2022 receiving hospice services, R1 passed away enroute back to facility at 12:47 pm.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 of California Regulations.

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20220126160751

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/27/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....This requirement is not met as evidenced by : Based on observation, records review & interviews,the licensee did not comply w/	1 2 3 4 5 6 7	Facility agrees to ensure that qualified staff will care for residents' according to their needs. Facility to provide Department with a plan on how facility staff will ensure that residents will have the qualified professionals to care for their needs by POC 4/27/2022 and
	8 9 10 11 12 13 14	the section cited above in 1 out of 6 resident needs which poses an immediate health & safety risk to persons in care. Dep. learned that resident R1 had pressure injuries after being admitted to hospital which facility informed they were unaware of.	8 9 10 11 12 13 14	proof of staff training with all staff names, signatures, date, time, and trainer name by POC date of 5/5/2022.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3