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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800848
Report Date: 10/27/2022
Date Signed: 10/27/2022 08:41:07 AM


Document Has Been Signed on 10/27/2022 08:41 AM - 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: 3DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Jerez Mercado - StaffTIME COMPLETED:
08:50 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced for the purpose of conducting a health and safety check on residents in care at the facility. LPA was greeted by live-in staff Jerez Mercado who is caring for 3 residents, 2 of which are on Hospice.

LPA toured the facility and there were no observed health and safety hazards, home was clean at a comfortable temperature and well-lit for resident’s safety. Hot water measured at 120 degrees F, which is within the required regulation of 105-120 degrees F. There was at least a 2-day supply of perishable and 7-day supply of nonperishable foods available to residents.

LPA observed residents comfortable watching television or in their bedrooms resting.


No deficiencies cited in the areas observed
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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