496800848-11-2-2022-21-AS-BMOS-CKYVZK-20221108155253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800848
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:30:59 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
11/02/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20221102091203

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: 3	DATE:	11/02/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Jerez Mercado - Staff		TIME COMPLETED:	01:32 PM

ALLEGATION(S):

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Unlawful Eviction
Facility failed to provide written notice to the residents and responsible parties of the Departments proceeding to revoke the license within 10 days.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA’s) Hansen and Arnhold arrived unannounced at facility to open a complaint and deliver findings regarding the allegations listed above. LPA’s met with staff Jerez Mercado.

The Department was provided a letter dated 10/24/2022 from licensee's counsel informing of the Departments action of revocation. The letter indicates the facility will be closing on December 16, 2022 which is the effective date of the order issued. The letter also indicates in part that there is a "potential buyer" and current licensee may be able to provide care until the "new operator is prepared to take over". The notice obtained during this complaint investigation is not a lawful eviction and did not contain all the components necessary per regulation 87224, therefore the notice is unlawful. On 10/31/2022 Administrator inquired to the Department via email about eviction notices which further supports the allegation the licensee failed to provide proper eviction notices to residents in care.

See 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: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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-20221102091203

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: 11/02/2022

NARRATIVE

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The Department of Social Services Community Care Licensing (DSS/CCL) served accusations (7222096201, 7222096201B, 7222096201C and 7222096201D) on facility 8/23/2022. The Department served Licensee Rose Wilbor with the decision and order on 10/10/2022 and an amended order on 10/12/2022 indicating the effective date of the order, 12/16/2022. The letter obtained for residents responsible parties dated 10/24/2022 from Licensee counsel informed the Decision and Order is attached. Based on interviews the licensee failed to attach and provide the order. The investigation also revealed that the Licensee also did not provide the accusations to residents in care. CCL confirmed with local Ombudsman office that their office was not noticed and was verbally informed in the facility on 10/26/2022 of the revocation order which is in violation of the Health and Safety Code 1569.38. Based on the evidence obtained that the licensee did not provide the accusations or the decision and order to the residents in care, residents responsible parties or local ombudsman which is in violation of 1569.38.

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

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221102091203

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: 11/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/04/2022 Section Cited CCR 87224(5)(A)(1)	1 2 3 4 5 6 7	87224 Eviction Procedures(5)Change of use of the facility.(A)The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.(1).In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code	1 2 3 4 5 6 7	Licensee to provide proper eviction notices to all residents in care, POA's, & LTCO.
	8 9 10 11 12 13 14	Based on record review licensee did not give a lawful eviction and did not contain all the components necessary per regulation 87224.	8 9 10 11 12 13 14
Type B 11/04/2022 Section Cited HSC 1569.38(b)(1)	1 2 3 4 5 6 7	1569.38 Posting of licensing reports; disclosure to new residents (b)A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50.	1 2 3 4 5 6 7	Licensee to submit self certification they have provided acusation, and decision and order to residents, residents responsible parties, and LTCO by POC due date 11/4/2022.
	8 9 10 11 12 13 14	Based on record review and interviews licensee did not provide the accusations or the decision and order to the residents in care, residents responsible parties or local ombudsman.	8 9 10 11 12 13 14

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: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC9099 (FAS) - (06/04)

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