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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 12/27/2022
Date Signed: 12/29/2022 10:00:29 AM

Document Has Been Signed on 12/29/2022 10:00 AM - 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:MOGRACE RESIDENCEFACILITY NUMBER:
496803853
ADMINISTRATOR:GACEGU, MONICAHFACILITY TYPE:
740
ADDRESS:6299 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7884
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 8CENSUS: 5DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Micky Fatuma Selemani-CaregiverTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA), Dina Alviso, arrived unannounced to conduct a Required- 1 Year inspection, and met with a caregiver on duty, Micky Fatuma Selemani . Caregiver Micky contacted the Administrator by phone to notify her of the LPA's arrival. Licensee/Administrator Monicah Gacegu arrived to the facility within the hour of being notified. The inspection will focus on the Infection Control procedures and practices of this facility.

All staff have required criminal record clearance, and are associated. Staff have first aid certification as required. There are five(5) residents in care, and one(1)resident is on hospice care. Staff screen visitors, staff, and residents, as needed. Screenings are logged. Residents are observed for any changes, and changes are reported as required.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Administrator submitted to the Department the required Infection Control Plan. Facility has a required Emergency/Evacuation Plan. Fire clearance is approved for eight(8) non-ambulatory residents.-effective 8/9/2019.
Facility has a sufficient supply of food. Medications were locked up and inaccessible to residents in care. Toxins and cleaners were locked and inaccessible to residents in care. All exits were clear and unobstructed. Fire extinguishers were serviced and tagged, expires 5/27/23. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). LPA observed the Administrator and staff to be wearing masks as required, during the LPA's inspection.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator Mera Shaughnessey.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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