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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800848
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:35:15 PM

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
04/25/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220425140805
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: 3DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Administrator George WilborTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care

Facility does not provide activities for residents

Facility does not have sufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. Staff contacted Administrator who arrived 30 minutes later. LPA met with Administrator George Wilbor.

Facility does not provide activities for residents – It is alleged staff are not engaging the residents and the staff do not provide any actives for the residents beyond watching TV. Based on LPA’s observation of staff and residents at eleven visits this year (1/20/2022, 1/26/2022, 2/4/2022, 2/24/2022, 3/10/2022, 3/24/2022, 3/30/2022, 4/25/2022, 4/26/2022, 4/28/2022, and 5/12/2022) only two out of eleven visits LPA observed any activity other than watching television, which was staff counting the number of times resident was lifting their arms for exercise. LPA conducted multiple interviews with residents, information obtained from interviews was consistent that the facility offers no activities outside of TV. Therefore, required facility planned activities for residents per regulation 87219 have not been met and the above allegation is found to be Substantiated.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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 5
Control Number 21-AS-20220425140805
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: 06/07/2022
NARRATIVE
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Resident sustained multiple pressure injures while in care & Facility does not have sufficient staffing.

LPA conducted interviews, made observations and conducted record reviews that revealed no indication facility notified primary care provider of pressure injuries. LPA Interviews with staff revealed Licensee advised staff not to provide care to residents during NOC shift for financial compensation reasons. LPA’s interview with S1 revealed S1’s observation when arriving for AM shift approximately two weeks prior to R1’s first hospital visit 4/5/2022. S1 informed observation of R1 in soiled depends upon arrival to AM shift. LPA conducted interview with outside medical professional who informed attempts to train staff on repositioning of R1. Medical professional informed LPA it appeared staff were not competent in following through with nurse’s care instructions. Medical professional informed after training was provided on 4/15/2022, during subsequent facility visit R1 was observed flat on R1’s back and not having feet elevated and without pillow supports per home health nurses notes of April 28, 2022. On 4/28/22 visit home health nurse instructed to make sure R1’s position is changed every two hours. In medical documents (602) obtained from facility of R1 dated 4/10/2022, R1 has a stage 1 pressure ulcer on the right buttock and a stage 2 pressure ulcer on the left buttock, as well as an open wound at the perirectal area. Referral for Home Health was sent on 4/14/2022. R1 is medically obese, incontinent, with left sided hemiplegia. Interviews with S1 revealed Licensee instructed S1 to care for R1 because S1 was the only staff who could lift R1, although schedule reveals S2 & S3 were on shifts independently 6 hours per day at least 3 days per week and alone on weekends. Interviews with 3 out of 3 staff indicated they did not provide care at night to residents. R1 no longer resides at facilty responsible party has relocated due to concerns of care.

The preponderance of Evidence standard has been met: therefore, the above allegations are found to be Substantiated.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights given.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 9099D) 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: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20220425140805
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: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement
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Licensee/Administrator to ensure facility has sufficient staff to meet the needs of residents in care. Licensee/Administrator agrees to summit by EOB on 6/8/2022 a plan of how the facility will ensure sufficient staff will meet the needs of the residents in care.
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is not met as evidenced by: Based on records reviewed, interviews conducted, Licensee did not ensure sufficient staff were present to meet resident needs. This poses an immediate Health and Safety risk to residents.
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 This plan will indicate AM, PM, and NOC shift coverage.
Type A
06/08/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 (a)(2) Additional Personal Rights of Residents in All Facilities: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment...This requirement was not met as
evidence by
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Licensee/Administrator to ensure facility has sufficient staff to meet the needs of residents in care. Licensee/Administrator to submit date of when facility will conduct an all staff training to address observation of pressure injuries and for facility procedures to notify primary care.
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: Based on interviews conducted and records reviewed, facility did not provide assistance with toileting and daily care. This poses an immediate health, safety and personal rights risk to residents.
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 Facility to submit date for training by EOB 6/8/2022. Training to be submitted no later than 6/22/2022 with signed and dated log in sheet from all staff.
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: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220425140805
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: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
Section Cited
CCR
87219(a)
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87219 Planned Activities:(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced by:
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: Licensee to ensure activities are planned and organized to encourage residents to participate. Licensee to submit a weekly list of activities completed, both for memory care residents and assisted living.
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 Based on observation of 11 different visits & interviews conducted, Activities are not conducted as scheduled or not conducted in a manner engaging to residents. This poses a potential health risk to residents in care
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List to be sent weekly to CCL starting 6/13/2022 through 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: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/25/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220425140805

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: 3DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Administrator George WilborTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility bathroom does not have soap for hand washing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. Staff contacted Administrator who arrived 30 minutes later. LPA met with Administrator George Wilbor.

Facility bathroom does not have soap for hand washing – Complainant alleges there was no soap in the bathroom to wash one’s hands with. LPA conducted visits and made observations on 4/25/22, 4/26/22, 4/28/22, and 5/12/22 where LPA observed soap in residents’ bathrooms. LPA was unable to obtain information to support facility bathroom does not have soap for handwashing. Therefore, this allegation is unsubstantiated.

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5