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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 12/21/2023
Date Signed: 12/21/2023 05:30:53 PM


Document Has Been Signed on 12/21/2023 05:30 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: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:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Monicah Gacegu-AdministratorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst(LPA) Alviso conducting a Required- 1 Year, at approximately 3:30pm on 3/9/23, and met with Monicah Gacegu, Administartor. The caregiver, Consulata, contacted the Administrator to notify them the LPA had arrived.

There are currently five residents in care. The facility is fire cleared for eight (8) non-ambulatory. Hospice waiver is approved for three (3).

LPA reviewed one of the resident's files.

The LPA toured the facility with the caregiver Consulata. The bathrooms were clean and all had grab bars. There was sufficient lighting in the hallways, resident rooms, bathrooms, and in all common areas.

The LPA will continue this annual at a later date
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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