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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 02/13/2024
Date Signed: 02/13/2024 05:17:24 PM


Document Has Been Signed on 02/13/2024 05:17 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: DATE:
02/13/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tamra Richmond-Business Office Manager TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst(LPA) Alviso conducted a continued annual inspection, on 2/13/24 at approximately 1:30pm, and met with Tamra Richmond-Business Office Manager. Administrator was not available to meet with the LPA. The annual visit was started on 1/24/24, see LIC809 of that date.

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- effective 1/19/24; Fire cleared resident rooms/units are 157-187 on the first floor, and 257-287 on the second floor. Last fire drills were held on 1/31/24 and 1/17/24, per review of the facility's emergency drills binder. An elopement drill was held on 1/24/24, per review of the facility's elopement drills binder.
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. All resident bathrooms have grab bars, and non-slip flooring and/or mats for use as needed. The medications were locked up and stored appropriately as required. There was a sufficient supply of personal protective equipment (PPE) to use as needed.

LPA reviewed resident files. All files were complete.

LPA reviewed staff files. All staff have required criminal record clearance. Six (6) out of eight (8) direct care staff didn't have first aid, per file reviews. This deficiency will be cited, Personnel Requirements - General Section 87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D.

Deficiencies 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.

Appeal rights provided. 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: 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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Document Has Been Signed on 02/13/2024 05:17 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
CCLD Regional Office, 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: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General Section 87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff records], the licensee did not comply with the section cited above in [6) out of [8] staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
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Licensee/Administrator to ensure that all staff providing care to residents have first aid as required by regulation. Ensure all six (6) staff identified, obtain required first aid. Submit copies of first aid certificates to the Department by POC due date of 2/26/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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