496800848-6-30-2022-21-AS-BMOS-CG3P2Z-20220706105642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800848
Report Date: 06/30/2022
Date Signed: 06/30/2022 04:01:05 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
06/08/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20220608124410

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:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Licensee Rose Wilbor & staff Jerez Marcado		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Facility was not clean, safe, sanitary at all times

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen made an unannounced subsequent visit to the facility. The purpose of this visit is to deliver findings for the above allegation. LPA met with Licensee Rose Wilbor and staff Jerez Marcado.

Complaint alleges facility is not being kept clean, safe, and sanitary at all times. During the investigation LPA reviewed records, made observations at the facility and conducted interviews. On 5/18/22 it was reported facility had rodent droppings in the kitchen windowsill. Photos taken on 6/2/202 and submitted to Community Care Licensing (CCL) of kitchen windowsill indicate the facility is failing to provide a sanitary environment. Photos consist of kitchen windowsill with rodent droppings from one side of the sill to the other side. Another photo obtained of the door from the kitchen to the garage propped open for cat to enter. On 6/9/2022 LPA made an unannounced visit to facility to open complaint observed and took pictures of the kitchen windowsill with rodent droppings from one side to the other and underneath kitchen sink at the back wall a hole that goes through to the insolation area.
Continue on LIC 9099-C

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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220608124410

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: 06/30/2022

NARRATIVE

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LPA interviewed Administrator Wilbor on 6/9/2022 who confirmed a year ago they had rodents and called pest control companies 2 different times, although the problem was not solved for long. Administrator also informed facility tried poison and electric traps but that also did not work. A few months ago, facility got a cat to take care of the problem, the cat comes and goes from the kitchen to the garage. Staff confirmed facility got the cat to deal with the rodent problem and prop the kitchen door open to the garage for the cat. LPA ensured Administrator understands that all traps must be inaccessible to residents in care.

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, Chapter8), is being cited on the attached LIC 9099D. Appeal 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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220608124410

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: 06/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/15/2022 Section Cited CCR 87307(a)	1 2 3 4 5 6 7	87303 (a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on LPAs photos obtained, interviews, and declarations the Licensee/Administrator	1 2 3 4 5 6 7	Administrator will submit a copy of pest controle reciept and pictures showing hole in kitchen sink wall have been covered to ensure facility is kept sanitary and rodent issue has been taken care of, submit proof to CCL by POC 7/15/2022.
	8 9 10 11 12 13 14	did not ensure facility was kept safe/sanitary with rodent droppings found in kitchen windowsill on 3 different occasions, accessible to residents in care which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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