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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 03/05/2025
Date Signed: 03/05/2025 04:10:03 PM

Document Has Been Signed on 03/05/2025 04:10 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:VINCENT, THEFACILITY NUMBER:
216804010
ADMINISTRATOR/
DIRECTOR:		CORRINE BIANCOFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 336-1400
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 126CENSUS: 80DATE:
03/05/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Pari Manouchehri, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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At approximately 1:10PM, Licensing Program Analysts (LPAs) Magdaleno and Felias arrived unannounced to conduct a Case Management - Annual Continuation visit and were greeted by Administrator, Pari Manouchehri. Facility has an approved fire clearance for a total capacity of 126 individuals, where 126 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPAs were informed that there were 80 residents in care and 22 staff members on-site.

At approximately 1:15PM LPAs conducted a spot check of 8 clients files, all required documentation present. At approximately 3:00PM LPAs conducted a spot check of 6 resident medications. 1 of 6 residents were observed to have some medications not centrally stored or documented as required (technical violation issued).

No Deficiencies cited during visit.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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