496800848-7-16-2021-21-AS-SHAN-C4YPCB-20210716111139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800848
Report Date: 07/16/2021
Date Signed: 07/16/2021 11:11:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

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: 5	DATE:	07/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator Jeremy Mercado		TIME COMPLETED:	11:10 AM

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	Licensing Program Analyst (LPAs) Hansen & Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Jeremy Mercado. Facility has 5 residents present. During facility tour on 7/16/2021 with Admin Jeremy Mercado facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was last checked on 2-22-2021. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Sharp items were stored in locked in the kitchen. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. LPAs observed on 7/16/2021at 8:40 AM the staff room in the garage of the facility being used by staff to sleep; a bed, clothing, shoes, vitamins, etc. Staff on shift reported that the staff room is used by staff S1 who does not have active prints – they are pending process. The staff was not in the facility during this visit and there was nothing to identify the room was occupied by this particular staff. LPAs reminded administrator Jeremy Mercado that all staff must have a print clearance and be associated to the facility. Failure to ensure this or allow staff without cleared print to work or reside in the facility is subject to citations and civil penalties. Furthermore, facility submitted on 6/7/2021 a copy of renew liability insurance certificate that covers only $250,000 for each occurrence and $750,000 for aggregate. Per Health & Safety Code # 1569.605 all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. Department has requested licensee Rose Wilbor to submit proof of liability insurance according with Health & Safety Code by July 12, 2021. At this time facility doesn’t have a liability insurance according with Health & Safety Code # 1569.605 as stated by administrator Jeremy Mercado. (see copy, LIC 809-D) Continued on LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST. FRANCIS ASSISTED LIVING	FACILITY NUMBER: 496800848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 facility liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care. Department received on 6/7/21 a copy of facility liability insurance certificate that covers only $250,000 for each occurrance and $750,000 for aggregate. Licensee received a deadline from the Department of 7/12/2021 to be in compliance, however; facility doesn't have liability insurance according with H&S Code 1569.605. (see copy)
	POC Due Date: 07/30/2021
	Plan of Correction
1 2 3 4	Licensee understands that all facilities licensed by the Department must have a liablity insurance according to requirements to stay in compliance. Licensee to obtain a liability insurance in compliance with H&S Code # 1569.605 and submit a copy to the CCLD by due of 7/30/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST. FRANCIS ASSISTED LIVING	FACILITY NUMBER: 496800848
	VISIT DATE: 07/16/2021

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in front room/office area. Residents’ medications are stored and locked in cabinet in the kitchen. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents also have available Facetime and telephone calls when contacting with family members and others. Staff did not have PPE training which is required, and have obtained N-95 fit testing. LPAs recommended administrator follow up with agencies that provided training to get proof of training.

In addition, LPAs advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills had been conducted quarterly last being done 7/2020. LPA’s discussed with administrator that disaster drills are still required.

LPA’s had a discussion with administrator regarding visitation guidelines per PIN-21-17. LPA’s confirmed a negative COVID test is not required for visitors. LPAs discussed vaccinated and non-vaccinated visitor guidelines are discussed in the PIN. LPA will forward emailed copy of the PIN to Administrator and Licensee. LPA’s confirmed administrator gets PIN’s automatically via email. LPAs recommended administrator ensure appropriate visitation signs are posted at the facility.

Facility to submit the following documentation to update facility file at CCL by 7/23/2021:
LIC 500
LIC 9120
LIC 308

Continued on LIC-809 C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST. FRANCIS ASSISTED LIVING	FACILITY NUMBER: 496800848
	VISIT DATE: 07/16/2021

NARRATIVE

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Appeal of 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.
There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC809 (FAS) - (06/04)

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