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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800848
Report Date: 08/30/2022
Date Signed: 08/30/2022 04:14:06 PM


Document Has Been Signed on 08/30/2022 04:14 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: 4DATE:
08/30/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Rosalinda Wilbor, Interim Administrator George Wilbor, & Jerez "Jay" WilborTIME COMPLETED:
04:00 PM
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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst (LPA) Shannan Hansen made contact on this date, via tele-visit, with Licensee Rosalinda Wilbor for the purpose of reviewing issues for Non-Compliance Conference. It is being conducted by tele-visit phone due to COVID - 19 precautions. Discussion was had regarding the Accusation served on August 23, 2022. It was encouraged that the Licensee review the Accusation and follow the guidelines laid out in the document. Accusation reference numbers; 7222096201, 7222096201B, 7222096201C and 7222096201D.

Due to areas of concern identified by the Department, Non Compliance Conference was held. Verbal commitment from Licensee/Administrator was received for 2 year Non-Compliance plan during conference.

Non Compliance Conference was held to discuss areas of concern and not limited to the below:
  • Liability Insurance

  • Staffing

  • Timely Medical & Observation of Residents

  • Training

  • Criminal Record Clearance

  • COVID MP/Protocols

  • POCs not resolved by agreed upon POC date, currently outstanding
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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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
VISIT DATE: 08/30/2022
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  • Medication and toxins accessible to residents in care/pre pouring of medication
  • Criminal Record Clearance
  • Rodent Issues


The licensee was informed that (2) civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

PIN 22-18 was sent to Licensee regarding Infection Control Plan.

Facility currently has two (2) COVID positive residents in care, LPA went over their procedures for ensuring infection control.

Community Care Licensing email a copy of the LIC9111 and LIC 809 for signature.

No deficiencies cited during the Non-Compliance Conference
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
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