496803933-7-15-2021-21-AS-CFGS-C4XM2V-20210715091410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 07/13/2021
Date Signed: 07/15/2021 09:14:17 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. MICHAEL ASSISTED LIVING		FACILITY NUMBER:	496803933
ADMINISTRATOR:	MORANCIL, ASTRID		FACILITY TYPE:	740
ADDRESS:	804 ST. FRANCIS ST		TELEPHONE:	(707) 763-8289
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 5	DATE:	07/13/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Marilynn Green - Licensee		TIME COMPLETED:	03:45 PM

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	Regional Manager Carla N. Martinez, Licensing Program Manager Bethany Moellers and Licensing Program Analyst Carla Fernandes-Goes conducted an office meeting with Licensee Marilyn Green, homeowner Rose Wilbor and her sons Jeremy Mercado & Jerez Mercado to discuss a request made by Rose Wilbor to associate staff to St. Michael’s. Rose if not the Administrator on record at St. Michael’s. Marilyn Green has a current lease agreement to control the property at 804 St. Francis Street in Petaluma. Rose has noticed the current Licensee of St. Michael’s of her wish to apply for a change of ownership after learning the current licensee is closing. At this time no application has come in. The license is NOT TRANSFERABLE. The current Licensee does not wish to pend the closure of her facility. A closure plan and eviction notices will be updated and resubmitted to residents in care. Families have already been notified. LTCO has been notified. Regional Office has been notified. The current licensee will continue to operate their facility per the Program Plan approved by the Department. The current licensee will ensure there is adequate staffing at all times, staff are associated and trained to St. Michael’s. The current licensee will ensure residents needs met at all times, and reassessments are done if additional care is needed. The current licensee has stated they will not be admitting new residents into care as their intent is to close. Residents and their families have been noticed of the intent to close. Licensee will adhere to admission agreement approved by CCL upon licensure. Administrator will be at facility at least 20 hours a week. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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. MICHAEL ASSISTED LIVING	FACILITY NUMBER: 496803933
	VISIT DATE: 07/13/2021

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Once the facility closes and the current residents are moved to other placement options, if the homeowner (Rose Wilbor) chooses to apply for a license they are able to do so.

Licensee agreed to do submit the following:

* Facility Closure Plan: licensee agreed to update closure plan and submit to CCL by 7/16/2021.

* Resident Eviction Notices: Licensee agreed to update eviction notices & reissued to families and submit copies to CCL by 7/16/2021.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

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