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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496800848
Report Date:
03/24/2022
Date Signed:
03/24/2022 09:08:56 AM
Document Has Been Signed on
03/24/2022 09:08 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 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:
4
DATE:
03/24/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
08:45 AM
MET WITH:
Staff Timoci Karavanua
TIME COMPLETED:
09:07 AM
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On 3/24/2022 at 8:45 am Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a 1 Year annual infection control inspection of the facility.
Due to unforeseen circumstances LPA had to leave and will return at a later date to conduct annual.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR NAME:
Shannan Hansen
TELEPHONE:
707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
03/24/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/24/2022
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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