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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 01/31/2023
Date Signed: 01/31/2023 03:00:40 PM


Document Has Been Signed on 01/31/2023 03:00 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: 26DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator, Matthew HorstmannTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/31/2023 to conduct a Required-1 Year inspection. This inspection is focused on the infection control practices and procedures of this facility. LPA met with administrator, Matthew Horstmann.

Facility has both independent living and assisted living. There are currently 26 residents in assisted living. LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. Facility is screening visitors and staff at the front entrance. Facility has a sufficient amount of personal protective equipment to support a resident in isolation. Facility has conducted infection control training with staff. Staff and residents are fully vaccinated and boosted. Facility had a sufficient amount of perishable and nonperishable food. Carbon monoxide and smoke detectors were observed throughout the facility. Fire extinguishers scheduled to be serviced in February. Toxins were observed locked and secured on housekeeping carts. Medications are centrally stored and secured.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
Evidence of Liability Insurance

Exit interview conducted with administrator and a copy of this report sent to his email.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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