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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 07/06/2023
Date Signed: 07/06/2023 12:07:06 PM


Document Has Been Signed on 07/06/2023 12:07 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:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Interim Administrator, Omar MendozaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of amending a LIC 9099-Complaint Investigation Inspection Report that was dated for June 20, 2023. LPA was greeted at the door by Administrator, Omar Mendoza and was granted access into the facility.

During the course of the investigation that was initiated on June 2, 2023, LPA learned that Reappraisals were not conducted in the year 2022 for Resident #1 (See LIC 9102-Technical Violation). LPA educated the Health and Wellness Director and Administrator on the importance of adhering to Reappraisals and ensuring that residents are getting Reappraised as outlined in Title 22 regulation.

No deficiencies were cited during today's Case Management-Other inspection. Exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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