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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 10/07/2021
Date Signed: 10/07/2021 05:45:53 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: DATE:
10/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Administrator -Steve SarineTIME COMPLETED:
05:55 PM
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Licensing Program Analyst (LPA) conducted a case management inspection and met with Administrator Steve Sarine, and Health & Wellness Director Emil DeGuzman.

Case management is being conducted to obtain more information on some resident (R1 & R2) incident reports submitted to the Licensing office

LPA reviewed the incidents with the Health Services Director, and obtained additional information and documentation. The incident reports had been reported as required to the licensing office, and all required parties and Agencies. LPA requested additional information be sent to the Licensing office regarding the incidents reviewed, and the H&W Director agreed to do so.

There are no deficiencies cited today.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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