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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:32:31 PM


Document Has Been Signed on 10/11/2022 03:32 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:
10/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Health and Wellness Director, Victoria MozaffariTIME COMPLETED:
03:45 PM
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At approximately 2:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit, and met with Health and Wellness Director, Victoria Mozaffari. The purpose of the visit is to follow up on two missing documents needed to establish Regional Director of Operations, Dave Peper, as the Administrator of Cogir of San Rafael, until the following occurs:
  • An individual is hired as Executive Director
  • Victoria Mozaffari receives their Active Administrator's Certificate and is processed as the Administrator.


LPA and Health and Wellness Director discussed the missing documents (LIC 503 Health Screening Report - Facility Personnel and Proof of a Negative TB Test.) LPA spoke with Regional Director of Operations over the phone and confirmed that an appointment has been made to complete the requirements.

The following documents to be submitted to Community Care Licensing (CCL) by the end of business on Friday, 10/11/2022
  • LIC 503 (Health Screening Report - Facility Personnel)
  • Proof of a Negative TB Test


Facility understands that all Administrator paperwork will need to be re-submitted for whomever is hired as Executive Director.

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: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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