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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 12/09/2021
Date Signed: 12/09/2021 12:08:18 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 SONOMAFACILITY NUMBER:
496803812
ADMINISTRATOR:MATTHEW HORSTMANNFACILITY TYPE:
740
ADDRESS:800 OREGON STTELEPHONE:
(707) 996-7101
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:45CENSUS: 31DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Matthew HorstmannTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required – 1 Year inspection at approximately 10:00 AM and was greeted by reception. At front entrance LPA signed in on an Accushield screening device. LPA met with administrator Matthew Horstmann and health/wellness director Norma Alvarez. There are currently 31 residents in assisted living. Facility has no memory care unit.

LPA toured facility with administrator and health/wellness director. The facility was found to be clean and a comfortable temperature. Toxins were observed to be locked and inaccessible on housekeeping carts. LPA observed the necessary personal protective equipment (PPE) to support a resident in isolation. All apartments are private therefore residents could isolate in their own apartment if necessary. Resident bathrooms contain necessary grab bars and non-slip floors/mats. Hand sanitizer was observed throughout the facility. Medication is centrally stored in in locked room on first floor of assisted living. Bedrooms are equipped with lighting and proper bedding that is clean and in good repair.

Staff were observed to be wearing masks, residents were also observed wearing masks. Staff were N95 fit tested as well as given infection control training in July by an outside party, CPR Survival. Facility has a 100 percent vaccination rate for staff/residents in assisted living. Facility is the process of obtaining booster shot and flu shot for staff/residents. Staff are discouraged from coming in to work if they feel ill. Activities include black jack and bingo. LPA observed chairs setup for social distancing in activity room.Current visitation policy is to have visitors screened and sign in at front entrance. Dining room is open for service and allows for social distancing. Visitors can visit in resident apartments although some prefer to visit in the courtyard. Fire extinguishers were last inspected January 22, 2021. LPA requested the following documents: Emergency Disaster Plan and Liability Insurance.

Exit interview conducted with administrator. LPA unable to print, will email a copy of the report to the administator. No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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