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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:41:13 PM


Document Has Been Signed on 01/24/2024 04:41 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 ROHNERT PARKFACILITY NUMBER:
496803807
ADMINISTRATOR:ACUMABIG, JOSEFACILITY TYPE:
740
ADDRESS:4855 SNYDER LANETELEPHONE:
(707) 585-7878
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:45CENSUS: 21DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jose Acumabig-AdministratorTIME COMPLETED:
04:55 PM
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Licensing Program Analyst(LPA) Alviso conducted Required -1 Year inspection, on 1/24/24 at approximately 2:45pm, and met with Administrator Jose Acumabig. Currently there are twenty-one (21) residents in care.

The facility has a required infection control plan. LPA toured the assisted living area, first (1st) and second (2nd) floors. All resident units have been renovated, but two. These two units are now vacant, and will be renovated before being occupied. All bathrooms observed by the LPA, had grab bars as required/needed for resident use. All fire extinguishers were serviced and tagged.
Facility has applied for an increase in capacity; Facility requested to go from forty-five residents, to a total of seventy-five residents. Facility fire clearance is approved for seventy-five (75) non-ambulatory residents- effective 1/19/24; Fire cleared resident rooms/units are 157-187 on the first floor, and 257-287 on the second floor. The facility will now be licensed for seventy-five (75) non-ambulatory residents; The increase in capacity is approved, effective 1/24/24.

LPA is requesting the following documents be updated and submitted by 2/24/24
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan -Update if changes, submit copy and/or a letter/ last page of annual review completed
Infection Control Plan- Update if changes, submit copy and/or a letter/ last page of annual review completed
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond if handling cash.
Copy of Current Liability Insurance
Copy of current Administrator Certificate

The annual inspection will be completed by the Department at a later date.
No deficiencies cited today.
Exit interview conducted with Administrator Jose Acumabig.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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