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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803810
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:37:51 PM


Document Has Been Signed on 01/12/2024 03:37 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 NORTH BAYFACILITY NUMBER:
486803810
ADMINISTRATOR:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:2261 TUOLUMNE STTELEPHONE:
(707) 552-3336
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:83CENSUS: 65DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tracy FreudendahlTIME COMPLETED:
03:45 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Executive Director Tracy Fruedendahl.

The building for this facility has four floors but the first three are licensed by Community Care Licensing Division (CCLD). The forth floor is independent living and not subject to CCLD. This community is a mix of studio, one bedroom, and two bedroom apartments. Each apartment has a full bathroom and small kitchenette. There are common laundry rooms for residents on each floor. There are several outdoor areas for residents. There are common areas on each floor.

Several resident and staff files were checked.

The following shall be updated and submitted to CCLD by 02/10/2024:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-paperwork appointing current executive director
-liability insurance

Multiple topics were discussed

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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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