216804000-3-23-2022-21-AS-FSAI-CCSUEE-20220323153101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 03/23/2022
Date Signed: 03/23/2022 03:31:28 PM

Document Has Been Signed on 03/23/2022 03:31 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:	COGIR OF SAN RAFAEL		FACILITY NUMBER:	216804000
ADMINISTRATOR:	DOWELL, CAROL		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(415) 472-6530
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70	CENSUS: 43	DATE:	03/23/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Administrator, Carol Dowell Health Director, Victoria Mozzafari		TIME COMPLETED:	03:43 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 unannounced for the purpose of conducting a Post-Licensing inspection. LPA was greeted at the door by Administrator, Carol Dowell and Health Director Victoria Mozzafari. LPA toured the facility with the Administrator and the Health Director. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on April 2021. The kitchen fire extinguisher was last charged on June 2021. Facility smoke detectors detectors are hard wired and sound directly to the fire station. Carbon Monoxide detectors were tested and found to be operational on all floors. Disaster Drills were conducted March 22, 2022. 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 within Title 22 acceptable regulation of 105 to 120 degrees F in residents rooms. 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 is available for residents any time of the day. Egress doors and elevator were operational during the inspection. 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. There is a daily activity schedule for residents on floor #2. Medications were centrally stored and secured. First Aid kit was appropriately filled. Toxins are stored in the laundry room. 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. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 03/23/2022

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LPA requested the following documents be sent to CCL:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

No deficiencies observed or cited during today's Post Licensing inspection. Exit interview was conducted and a copy of this report was emailed to the Facility Administrator and Health Director, Victoria Mozzafari.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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