496803807-2-13-2025-21-AS-DALO-DDV3FN-20250213171301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 02/13/2025
Date Signed: 02/13/2025 05:13:06 PM

Document Has Been Signed on 02/13/2025 05:13 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 ROHNERT PARK		FACILITY NUMBER:	496803807
ADMINISTRATOR/ DIRECTOR:	ACUMABIG, JOSE		FACILITY TYPE:	740
ADDRESS:	4855 SNYDER LANE		TELEPHONE:	(707) 585-7878
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY: 75	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	02/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Tamra Richmond, Business Office Manager		TIME VISIT/ INSPECTION COMPLETED:	05:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(LPA) Alviso conducted an annual inspection, on 2/13/25 at approximately 1:40pm, and met with Tamra Richmond, Business Office Manager. Jose Acumabig, Administrator was not on-site today and available to meet with the LPA. The facility has a required infection control plan. Hospice waiver is approved for ten (10) residents only. The facility has a required emergency and disaster plan. Facility is fire cleared for seventy-five (75) non-ambulatory residents. Fire cleared resident rooms/units are 157-187 on the first floor, and 257-287 on the second floor. LPA reviewed six (6) resident files. All files were complete. LPA reviewed six (6) staff files, including training. Per record reviews, last fire drill was 1/29/25 and last elopement drill was on 9/25/24. LPA met with the Activity Director Shaianne Chantavong, and reviewed the facility's activity calendars; Per review of records, activities are being conducted with assisted living residents as required. LPA observed that all stairwells of the facility had evacuation chairs, to be used as needed for residents in an emergency. There was a sufficient supply of food, perishable and non-perishable. The medications were locked up and stored appropriately as required. Medication narcotics were double locked and counted on each shift. PRN and medication records were found to be accurate, and maintained as required. There was a sufficient supply of personal protective equipment (PPE) to use as needed. Sufficient supply of disinfectants/cleaners, and paper products. All cleaners/disinfectants were locked up and inaccessible as required. Sufficient furnishings for residents use. All hallways throughout the facility had sufficient lighting for residents in care. Fire extinguishers were serviced and tagged as required. All exits were free and clear of obstruction. The facility was at a comfortable temperature for residents in care. LPA observed residents engaged in a facility activity during the inspection. Continued on LIC809C..

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 02/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ROHNERT PARK	FACILITY NUMBER: 496803807
	VISIT DATE: 02/13/2025

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 3/13/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan -Update if changes, submit copy and/or copy of last page of annual review completed
Infection Control Plan- Update if changes, submit copy and/or copy of 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

The following deficiency was observed during the inspection:

LPA checked a resident bathroom sink, and the hot water was checked at 122.9 degrees Fahrenheit, which is not within regulation. Deficiency cited,87303 (e) (2) Maintenance & Operation- Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C), see LIC809D.

Deficiency will be cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Tamra Richmond, Business Office Manager.

Evaluation report LIC809/809D and Appeal rights were provided to Tamra Richmond, BOM, for Administrator Jose Acumabig.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2025 05:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ROHNERT PARK	FACILITY NUMBER: 496803807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, LPA checked a resident bathroom sink, and the hot water was checked at 122.9 degrees Fahrenheit, which is not within regulation., the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure the hot water heater is turned down and the hot water is within regulation, no lower than 105. degrees Fahrenheit and no higher than 120. degrees Fahrenheit. Submit plan of correction. Submit log of monitoring the hot water for a period of five days. Copy of hot water log submitted by 2/20/25. POC due 2/14/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 02/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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