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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:43:21 PM

Document Has Been Signed on 10/29/2024 02:43 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:COGIR OF SAN RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR/
DIRECTOR:		CLAREY, KAITLYNFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(707) 334-1620
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 70CENSUS: 46DATE:
10/29/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Executive Director, Kimberly HumphreyTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met Executive Director, Kimberly Humphrey.

LPA requested and reviewed documents for all employees hired from July 2024 to October 2024. Review of documents showed that facility hired 2 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas:
  • Reporting Requirements
  • Personal Rights
  • Incidental, Medical, and Dental Care
  • Welfare and Institutions Code
  • Administrator and Designated Representatives


LPA received Administrator paperwork to update Administrator to Kimberly Humphrey. Administrator paperwork to be processed. LPA and Executive Director did a walkthrough of the facility.
No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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