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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:18:08 PM


Document Has Been Signed on 10/06/2022 03:18 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 RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR:DOWELL, CAROLFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(415) 472-6530
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: DATE:
10/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Resident Care Coordinator, Sean Bannister and Health and Wellness Director, Victoria Yazdi Mozafarri, TIME COMPLETED:
03:30 PM
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At approximately 12:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit, and met with Resident Care Coordinator, Sean Bannister. Health and Wellness Director (HWD), Victoria Mozaffari, arrived later during visit at 1:45PM. The purpose of the visit is to follow up on Administrator paperwork and to discuss vaccinations recently conducted at the facility.

LPA conducted a walk-through of the facility with Resident Care Coordinator. LPA observed the following: Residents were participating in activities in a variety of areas, and the facility was clean with no exits being obstructed.

LPA and Health and Wellness Director discussed the following:
  • The Administrator paperwork that was due for Victoria Mozaffari. Currently, Facility plans to have Health and Wellness Director be the current Administrator until a new one is hired by Corporate. At this time, their Administrator's Certificate is in pending status. Once approved and in Active status, Administrator paperwork for Victoria Mozaffari will be processed by LPA for Change of Administrator. Facility understands that until this status is changed, Victoria cannot be the Administrator and fulfill those duties. The role and duties of Administrator will have to be conducted by Dave Peper, Director of Regional Operations.
    • Dave Peper's Administrator Paperwork to be submitted to Community Care Licensing (CCL) by the end of business, Friday, 10/7/2022.
  • Vaccinations that were conducted on Monday, 9/26/2022 by Kaiser Permanente
  • Special Incident Reports (LIC 624)

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

No Deficiencies cited during visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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