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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801242
Report Date: 03/30/2022
Date Signed: 03/30/2022 01:23:50 PM

Document Has Been Signed on 03/30/2022 01:23 PM - 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 2FACILITY NUMBER:
496801242
ADMINISTRATOR:MERCADO, JEREMY G.FACILITY TYPE:
740
ADDRESS:1724 MOCLIPS DR.TELEPHONE:
(707) 763-0816
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 4DATE:
03/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Jeremy MercadoTIME COMPLETED:
01:23 PM
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On 3/30/2022 at approximately 1:00 PM licensing Program Analyst (LPA) Hansen arrived unannounced and met with Jeremy Mercado-Administrator regarding an uncleared citation pertaining to liability insurance.
Administrator was unable to provide proof of liability insurance per health and safety code section 1569.605. A citation was originally cited by LPA Fernandez-Goes on 7/16/2021 while conducting a case management, POC date was 7/30/2021 and facility failed to clear this citation. LPA Hansen reissued a citation HSC Section 1569.605 on 2/24/2022, with a POC date of 3/3/2022 and facility has failed to clear this citation. On 3/10/2022 LPA Hansen conducted a case management to issue civil penalties due to failure to correct citation issued on 2/24/2022 for the period of 3/4/2022 to 3/9/2022 (at $100 per day) totaling $600. Due to failure to clear citation and obtain liability insurance per regulation civil penalties are being issued today in the amount of $2,000.00 ($100. per day from 3/10/2022 - 3/29/2022). Administrator was informed that civil penalties may accrue of $100 per day until citation is cleared.


Civil Penalties are being assessed in the amount of $2,000 due to not having liability insurance according to requirements.

*****Total Civil Penalties issued today in the amount of $2,000.00

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.

LIC421FC: Failure to Correct.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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