<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803735
Report Date: 12/09/2021
Date Signed: 12/09/2021 03:15:51 PM

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:COGIR OF SAN RAFAELFACILITY NUMBER:
216803735
ADMINISTRATOR:CAROL DOWELLFACILITY TYPE:
740
ADDRESS:111 MERRYDALE RDTELEPHONE:
(415) 472-6530
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: 44DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Health Director, Victoria Mozzafari and Regional Nurse, Ethelia Hines.TIME COMPLETED:
03:30 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
Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Cogir of San Rafael for the purpose of conducting a Required 1 year inspection. LPA was met at the door by Sales Director Allison Rodman. Sales Director directed me to Health Director, Victoria Mozzafari and Regional Nurse, Ethelia Hines.

LPA toured the facility with Health Director and Regional Nurse. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were free from obstructions at the time of the inspection. Fire Extinguisher was found to be last charged on 04/2021. Facility smoke detectors and Carbon Monoxide detectors are hard wired and sound directly to the fire station. Disaster Drills were conducted 12/2021. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 114.2 degrees F and 118.4 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F. The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Menus are available and provided during meals. LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. LPA requested an updated facility sketch and an updated Liability Insurance.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has already been N95 Fit tested. Staff has had training on PPE and PPE is sufficient in the facility..

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Facility Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5