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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 07/17/2023
Date Signed: 07/17/2023 10:35:36 AM


Document Has Been Signed on 07/17/2023 10:35 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:COGIR OF SAN RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR:SUSAN EDWARDSFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(415) 472-6530
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: 50DATE:
07/17/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director/Administrator, Susan EdwardsTIME COMPLETED:
10:45 AM
NARRATIVE
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An Office meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Licensing Program Manager, Bethany Moellers, Licensing Program Manager, Kimberley Mota, Licensing Program Analyst, Caitlynn Felias, Cogir Executive Vice President of Operations, Benoit (Ben) Levesque, Executive Vice President of Care and Compliance, Holly McMurray, Executive Director, Susan Edwards, and Joel Goldman, Partner with HansonBridgett.

The purpose of the office meeting was to hold a Non-Compliance (NCC) meeting to address areas of concern identified by the Department.

The following areas were discussed:

  • Reporting Requirements related to
    • Personal Rights
    • Incidental, Medical, and Dental Care
    • Welfare and Institutions Code
    • Administrator and Designated Representative
Facility's Non Compliance Plan will be in place for 2 years.

The issuance of a Civil Penalty is under review. The Licensee is being informed that a Civil Penalty might be assessed based on a violation that the Department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident.

No Deficiencies Cited during the Non-Compliance Conference

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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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