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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:51:37 PM


Document Has Been Signed on 01/24/2024 03:51 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:COGIR OF SONOMAFACILITY NUMBER:
496803812
ADMINISTRATOR:RAFAEL MENDOZAFACILITY TYPE:
740
ADDRESS:800 OREGON STTELEPHONE:
(707) 996-7101
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:82CENSUS: 23DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Rafael Mendoza, AdministratorTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Rafael (Omar) Mendoza, Administrator. Facility currently has 3 residents on hospice which is allowable per the facility's Hospice Waiver. Facility contact information was reviewed.


At approximately 10:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 113.2 and 117.2 degrees F, respectively which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 2/10/2023. Facility's fire system is maintained by a vendor and the most recent test/service of the system was conducted 2/23/2023. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 11/29/2023. Facility has a backup generator for use during a power outage.

At approximately 12:30pm LPA conducted resident interviews. At approximately 2:30pm LPA conducted Staff interviews.

No deficiencies cited during today's visit.LPA unable to complete annual inspection today, will return at a later date to complete. Any observed deficiencies will be addressed on return visit. Exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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