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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 02/22/2022
Date Signed: 02/22/2022 05:13:11 PM


Document Has Been Signed on 02/22/2022 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 23DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Emil DeGuzman-Health & Wellnness DirectorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Alviso. LPA is conducting a 1 Year inspection, and met with Health & Wellness Director Emil DeGuzman. The inspection is focused on the Infection Control procedures and practices of this facility.

Currently twenty-three(23) residents in care, and one resident receiving hospice care. Hospice care waiver approved five(5) residents. Mitigation plan reviewed by the Department on 3/31/21. Fire clearance approval is for forty-five (45) non-ambulatory. The facility does not have a dementia care plan of operation.
Facility offers activities during the day for those wanting to participate; Pandemic policies are in place. All visitors are screened upon entering the building; All visitors have their temperatures taken and answer all screening questions. Residents are screened daily, and observed for any changes, including a temperature check. All staff are screened before each shift, including temperatures taken. All exits were observed by the LPA to be free from obstruction. The facility fire extinguishers were serviced and tagged as required-expires 3/1/22; Health & Wellness Director(HWD) stated the service company would be out soon to inspect the fire extinguishers and service them. The facility has a large sufficient supply of personal protective equipment (PPE). Bathrooms observed had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. HWD stated that staff wear masks in the facility at all times, and also when providing care services to the residents in and out of the facility. HWD had a mask on during the LPA's inspection. Administrator stated that the facility is following and operating in compliance with the mitigation plan.

LPA cited no deficiencies today. Exit interview with HWD.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
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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