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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 09/09/2021
Date Signed: 09/09/2021 06:55:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:COGIR OF ROHNERT PARKFACILITY NUMBER:
496803807
ADMINISTRATOR:SARINE, STEVEFACILITY TYPE:
740
ADDRESS:4855 SNYDER LANETELEPHONE:
(707) 585-7878
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:45CENSUS: 27DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Steve Sarine-AdministratorTIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Dina Alviso , arrived unannounced to conduct an Annual Required inspection and met with Administrator Steve Sarine. The inspection is focused on the Infection Control procedures and practices of this facility.

There is an approved hospice waiver for five (5) residents. Mitigation plan was reviewed by the Department on 3/31/21. Fire clearance is approved for forty-five (45) non-ambulatory.
There were twenty-seven (27) residents in care at the facility during this inspection. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged in a Acushield screening system. Residents are screened three (3) times daily, observed for any changes, and all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection, and all other staff the LPA observed while touring the facility had masks on.
No deficiencies found in the areas inspected.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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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