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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:50:17 PM


Document Has Been Signed on 10/05/2022 02:50 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 SONOMAFACILITY NUMBER:
496803812
ADMINISTRATOR:MATTHEW HORSTMANNFACILITY TYPE:
740
ADDRESS:800 OREGON STTELEPHONE:
(707) 996-7101
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:45CENSUS: 30DATE:
10/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Matthew HorstmannTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct a case management visit. LPA was greeted Norma Alvarez (NA), and met with Executive Director, Matt Horstmann (MH) later.

LPA, NA and MH discussed incident reports for 2022. Facility has only reported one incident. LPA conducted interviews and learned that there were no other reportable incidents within the facility.

No deficiencies cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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