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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 03/16/2023
Date Signed: 03/16/2023 06:16:02 PM


Document Has Been Signed on 03/16/2023 06:16 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:
03/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Jose Acumabig-AdministratorTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Alviso conducted a case management visit, and met with Medication Technician(med-tech), Leekiesha Hoalst. Jose Acumabig was contacted by the med-tech to notify them of the LPA's arrival. The Administrator was on the way to meet with the LPA.

The case management id being conducted to amend the Required 1-Year visit that was completed on 1/30/23. The amended report was left with the Administrator, and clearly states what was amended in the report.

No deficiencies cited on today's LIC809 Case Management. report.
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: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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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