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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 01/13/2025
Date Signed: 01/13/2025 02:53:24 PM

Document Has Been Signed on 01/13/2025 02:53 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/
DIRECTOR:		RAFAEL MENDOZAFACILITY TYPE:
740
ADDRESS:800 OREGON STTELEPHONE:
(707) 996-7101
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 82TOTAL ENROLLED CHILDREN: 0CENSUS: 26DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Rafael Mendoza, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:07 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Rafael "Omar" Mendoza: Administrator Certificate 7027912740 expires 6/19/26.

At approximately 9:30am 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.

Facility has Independent Living (IL) and Assisted Living (AL) residents. Facility does not offer Memory Care. LPA and Admin toured selected AL resident rooms: #101, #103, #114, and #208 . All bedroom bathrooms were equipped with an emergency pull cord and grab bars. Water temperature in sink accessible to residents in care measured at 114.3 in rooms #101 and #103, 113.5 in room #114, and 121.2 in room #208 degrees F which are within the allowable range of 105 to 120 degrees F, except for in room #208 which is not within the the allowable range. Admin advised LPA that facility has 8 water heaters. LPA and Admin agreed to lower the temperature of the water heater just slightly in order to ensure water temperature stays within regulation.

Fire extinguishers were last inspected 1/9/25. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired, last serviced by vendor on 8/26/24. Facility’s last quarterly disaster drill was conducted 12/13/24. Facility equipped with elevators, last service date 3/15/24.

At approximately 11:30am LPA conducted a review of 5 resident records. All documentation present. No deficiencies.


Continued on 809C...
Victoria BertozziTELEPHONE: (707) 588-5059
Christi CoppoTELEPHONE: (707) 588-5054
DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SONOMA
FACILITY NUMBER: 496803812
VISIT DATE: 01/13/2025
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Continued from 809...

At approximately 12:45pm LPA conducted review of 5 staff records. All documentation present. No deficiencies

At approximately 2:00pm LPA and Health and Wellness Director (HWD) conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. No deficiencies


LPA reviewed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility

No deficiencies cited. Exit interview conducted with Administrator and copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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