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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 09/09/2024
Date Signed: 09/09/2024 05:41:30 PM


Document Has Been Signed on 09/09/2024 05:41 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: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: 6DATE:
09/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Monicah Gacegu-Licensee/AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst(LPA) conducting a case management visit, at approximately 3:00pm on 9/9/24, and met with Monicah Gacegu-Licensee/Administrator. There are currently six (6) residents in care.
This case management is being conducted to address deficiencies found during the complaint inspection of earlier today. The deficiencies are unrelated to the complaint investigation.

LPA observed that the living room slider door has a broken lock, when the slider is in lock position it still opens up, this is a health and safety risk to residents in care. This deficiency will be cited, 87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors, see LIC809D.

Per interviews and resident record requests, R1 lacks admittance documents as required per regulation, no records on-file/on-site for R1. This deficiency will be cited, 87506(a)(b) Resident Records-The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff, see LIC809D.

Per interviews, and record requests, S2 lacks required staff training for direct caregivers, the forty (40) initial required RCFE training hours. Staff S2 has worked approximately for six (6) months. This deficiency will be cited, 87411(c) Personnel Requirements – General, All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69, see LIC809D

Licensee/Administrator has agreed to submit an updated personnel report, LIC500, of staff schedule, days/hours working, 24/7 staffing. Licensee/to submit copy of R1's appraisal, and copy of R1's care plan, copy of facility activities, and resident roster. Submit the above records by 9/12/24.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D.
Failure to correct deficiencies as required may result in additional citations and civil penalties, including deficiencies re-cited within 12 months.
Exit interview conducted.
Appeal Rights Given to Monicah Gacegu-Licensee/Administrator.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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 3


Document Has Been Signed on 09/09/2024 05:41 PM - It Cannot Be Edited

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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2024
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee/Administrator to ensure the lock on the living room slider door is repaired and/or replcaced so the lock works as it should. The living room slider door should lock appropriately, and be secure, for all residents residing in the facility. Submit receipt of purchase of new lock and materials and submit written confirmation that the door is working/locking appropriately as it should. POC due 9/11/24.
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LPA observed that the living room slider door has a broken lock, when the slider is in lock position it still opens up. This is a risk to the health and safety of residents in care.
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Type B
09/16/2024
Section Cited
CCR87506(a)(b)

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87506(a)(b) Resident Records-The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Each resident’s record shall contain at least the following information, see regulation.
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Licensee/Administrator to ensure that all required documents for admitting residents into the facility are completed, signed/dated as needed, onsite at the facility, and available for review as required. POC due 9/16/24.
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This requirement was not met as evidenced by: Per interviews and resident record requests, R1 lacks admittance documents as required per regulation, no records on-file/on-site for R1. This is a risk to personal rights and/or a risk to health & safety of residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/09/2024 05:41 PM - It Cannot Be Edited

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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2024
Section Cited
CCR
87411(c)

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87411(c) Personnel Requirements – General- All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by:
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Licensee/Administrator to ensure S2 obtains required RCFE 40 hour training. Submit proof of training, meeting all H&S code 1569.625 and 1569.69 training requirements (specific training/specific number of hours). POC due 9/30/24.
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Per interviews, and record requests, S2 lacks required staff training for direct caregivers, the 40 initial required training hours. Staff S2 has worked approximately six (6) months. This is a risk to personal rights and/or a risk to health & safety of residents.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3