496800848-2-24-2022-21-AS-BMOS-CC5TB5-20220302133433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800848
Report Date: 02/24/2022
Date Signed: 02/24/2022 12:25:36 PM

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
01/13/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20220113153615

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:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Jeremy Mercado - Administrator		TIME COMPLETED:	12:24 PM

ALLEGATION(S):

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Staff are not following COVID -19 protocols

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. On 2/24/ 2022 at 11:50 am licensing Program Analyst Shannan Hansen arrived unannounced for the purpose of closing the investigation and met with Jeremy Mercado, Administrator.

On 1/14/2022 Community Care Licensing (CCL) and Sonoma County Local Public (LPH) nurse conducted a PCC tele-visit with Jeremy Mercado, Administrator at facility due to residents testing positive for COVID-19. During virtual PCC visit Administrator and staff were observed wearing surgical masks and advised/instructed by LPH nurse for all staff to wear N95 masks due to exposure and to prevent further spread of COVID-19. Administrator and staff put on N95 masks during virtual call and Administrator confirmed understanding. Administrator was sent a follow up email reminding of COVID 19 protocols at tele-visit stating on 1/14/2022, “At the beginning of the visit you and your staff were wearing surgical masks. As discussed, you and your staff are considered exposed and need to be wearing N95 masks. You informed you have a sufficient supply.”
Continued on 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: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 21-AS-20220113153615

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: 02/24/2022

NARRATIVE

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On 1/20/2022 LPA Hansen arrived at facility to conduct a 10-day complaint inspection and observed staff (S1) not wearing appropriate N95 mask as discussed with Administrator, S1 was observed wearing a surgical mask. During 1/20/2022 visit LPA was not screened for COVID-19 before entering the facility. Screening protocol was discussed with Administrator during PCC virtual visit and Administrator confirmed understanding. Administrator informed that he contacted LPH to inform of COVID positive residents and received an email response. CCL and LPH requested the LPH response email be forwarded after PCC call, LPH has no record of COVID positive notification from facility. Administrator failed to provide requested email. LPH nurse made multiple attempts to reach Administrator via email to initiate COVID testing in the facility. Due to Administrator’s failed response LPH nurse reached out to CCL for assistance. After multiple attempts Administrator complied. After an outbreak at Licensee’s sister facility (ST. Francis Assisted Living 3, 496801702. Please note; facility is no longer operating and the license has been revoked) the Department had great concern and hired a consultant firm to review in person infection control and provide recommendations at Licensee’s other two CCL facilities. On 11/3/2020 consultant met with Rosalinda Wilber, Licensee to provide extensive review of infection control at this facility. Based on the report provided to the Licensee the consult identified areas of concern and an action plan to improve/add preventative measures to ensure adequate infection control.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

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: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 21-AS-20220113153615

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: 02/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/05/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator agrees to review Mitigation Plan and correspondance regaring mitigating the spread of COVID 19 in the bulding. Admin agrees to Self Certify the understanding of plan set out by DSS, Community Care Licensing, Dept. of Public Health, and Local Public Health mandates.
	8 9 10 11 12 13 14	Based on LPAs observations and interviews which were conducted and record reviews, the facility did not follow LPH guidance by wearing appropriate N95 masks and screaning of visitors entering facility.	8 9 10 11 12 13 14	Administrator agrees to submit written statement by POC date of 2/25/2022.
Type B 02/05/2022 Section Cited CCR 87405(d)(2)	1 2 3 4 5 6 7	87405(d)(2) Administrator Qualificaitons and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.	1 2 3 4 5 6 7	Administrator agrees to submit a statment informing how he will ensure all CCL and Public Health guidance is followed. Administrator agrees to submit statement by POC date 3/3/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on LPAs observations the facility is not screening staff and visitors.	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: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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