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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 07/23/2025
Date Signed: 07/23/2025 02:31:14 PM

Document Has Been Signed on 07/23/2025 02:31 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: 82CENSUS: 28DATE:
07/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Rose Lazzarotto, Business Office ManagerTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by concierge. LPA met with Rose Lazzarotto, Business Office Manger (BOM). Administrator Omar Mendoza was available by phone.

On 6/16/25, facility submitted incident report indicating on 6/7/25 resident (R1) exited the community unassisted. Facility is located close to boutique hotel Pueblo Inn. A staff member of Pueblo Inn called the facility to alert them that R1 was at their property. Administrator sent staff S1 over to accompany R1 back to the facility. At approximately 11:00am S1 found R1 and accompanied them back to the facility. Health and Wellness Director (HWD), Norma Alvarez immediately notified R1’s family member and Primary Care Physician of elopement. Admin then discussed with family the need for a companion due to new exiting behavior exhibited. Companion was provided to R1 by family. However, Admin felt that transfer to a facility with Memory Care could be a positive intervention to her benefit, as risk of exiting behavior may continue in Assisted Living. So, R1 was moved to a sister community's Memory Care unit. R1 left facility on 6/30/25.

Incident report indicates R1 has diagnosis of dementia. LPA reviewed R1's physician report and Care plan. Physician's report indicates that R1 did not have a history of disorientation, unsafe wandering, elopement, or sundowning behavior. However, physician's report indicates that R1 is not allowed to leave the facility unsupervised. LPA reviewed Care plan, Care plan indicates that R1 had mild neurocognitive impairment, but had no impairment with vision, hearing, communication, ambulating, or history wandering/elopement. When R1 was found by S1, R1 seemed anxious and stating they “wanted to go somewhere,” but care plan indicated that resident did not have current or history of anxiety. Admin advised LPA that in 6/3/25 R1 was moved from Independent Living to Assisted Living, as physician's report and care plan both indicated resident did not have history

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/23/2025
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of wandering behavior, sundowning behavior, or elopement, so resident not identified with risk of elopement. Admin advised LPA that he believes incident of elopement was not the result of a lack of staff supervision, but rather perhaps a progression of their dementia. Additionally, Admin disagrees with physician report assessment of R1 not being able to leave the facility unassisted as R1's physician report also indicates that R1 does not experience disorientation, lack of hazard awareness, lack of impulse control, unsafe wandering, elopement, sundowning behavior, expressions of frustration, hallucinations, or any other history of behavioral expressions that would make R1 at risk for elopement. LPA and Admin discussed thoroughly reviewing all residents' physician reports and if any discrepancies are found, Admin to immediately address discrepancies and get revised physician's report, if needed. Admin understands and agrees.

No deficiency cited.

Exit interview conducted with Administrator via telephone and a copy of this report was given to BOM.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
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