496803812-3-2-2022-21-AS-KMOA-CCMVM8-20220318163306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803812
Report Date: 03/02/2022
Date Signed: 03/02/2022 09:53:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2021 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20211228154817

FACILITY NAME:	COGIR OF SONOMA		FACILITY NUMBER:	496803812
ADMINISTRATOR:	MATTHEW HORSTMANN		FACILITY TYPE:	740
ADDRESS:	800 OREGON ST		TELEPHONE:	(707) 996-7101
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	45	CENSUS: 31	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator, Matthew Horstmann		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide a safe environment for resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 3/2/2022 to deliver the findings of the complaint investigation regarding the allegation above.

There is an allegation of facility does not provide a safe environment for resident. Reporting Party (RP) had stated that the facility sprays chemicals inside the facility which are toxic. RP described the chemcials as a fragrance which are peridocally sprayed throughout the facility. During the course of the investigation LPA made two unannounced visits. LPA toured the facility, made observations, conducted interviews, and reviewed documents. The source of the scent are fragrance oil dispensers dispersed throughout the facility. Disepenser releases fragrance on timed intervals. LPA requested a dispenser be opened and observed the fragrance oil bottle which was unlabeled. The facility was able to provide a safety data sheet which profiled the chemical.

Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 21-AS-20211228154817

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 SONOMA	FACILITY NUMBER: 496803812
	VISIT DATE: 03/02/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The safety data sheet indicated that the material does not present a hazard if inhaled or require special clean up procedures if spilled. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview was conducted with administrator and a copy of this report provided to the facility.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2