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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 01/29/2026
Date Signed: 01/29/2026 05:10:16 PM

Document Has Been Signed on 01/29/2026 05:10 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: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: DATE:
01/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Rafael MendozaTIME VISIT/
INSPECTION COMPLETED:
05:24 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Rafael "Omar" Mendoza: Administrator Certificate 7027912740 expires 6/19/26.

At approximately 10:00am LPA toured Assisted Living rooms. LPA observed pull cords and grab bars present in resident bathrooms. Facility has Independent Living (IL) and Assisted Living (AL) residents. Facility does not offer Memory Care. LPA and Admin toured selected AL resident rooms: #108, #111, #115, #202, and #205.

Administrator then joined LPA and toured the rest of the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Freezer and refrigerator temperature logs present. All temperatures observed are in compliance with regulation. LPA observed hot water sign present in dish washing area. Kitchen utilizes hot bar bain marie, all foods properly stored and covered within the bain marie. Pantry item bins all properly sealed and labeled.

Water temperature in sink accessible to residents in care measured at 118.6 degrees F in room #108, 116.3 degrees F in room #111, 117.7 degrees F in room #115, 115.7 degrees F in room #202, and 117 degrees F in room #205 degrees F which are all within the allowable range of 105 to 120 degrees F. LPA measured water temperature in movie room, hot water was turned off. Administrator immediately called maintenance to address the issue of it being turned off.

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2026
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: 01/29/2026
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Continued from 809...

Fire extinguishers were last inspected 1/9/25, but showing as fully charged. Per Administrator, vendor servicing fire extinguishers is set for next week. However, he requested for them to come out earlier next year in order to avoid being slightly over on the annual servicing. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired, last serviced by vendor on 2/13/25. Sprinklers throughout facility are serviced by vendor, last date of service 6/13/25. Facility’s last quarterly disaster drill was conducted October 2025. LPA discussed with Administrator making sure disaster drills are conducted quarterly. Facility equipped with elevators, all elevator permits are active expiring 7/31/26.

At approximately 12:30pm LPA conducted a review of eight [8] resident records. All documentation present. No deficiencies.


At approximately 2:30pm LPA conducted review of seven [7} staff records. All documentation present. No deficiencies.

At approximately 3:30pm LPA and Health and Wellness Director (HWD) conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. LPA and HWD observed two medication errors for resident (R1). Start date for Levothyroxine 1/1/26, R1 is to receive one [1] tab per day; however only one [1] tablet remaining in 31 tab bubble pack, so bubble pack missing one dose. Start date for Florastor 1/16/26, R1 is to receive 2 capsules per day; however 5 capsules remain in 31 capsule bubble pack, so there is one [1] capsule too many (deficiency cited, see 809D).


LPA and Administrator reviewed facility's Infection Control Plan and Emergency Disaster plan. Administrator provided LPA with updated copy.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2026 05:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/29/2026 at 04:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SONOMA
FACILITY NUMBER: 496803812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and HWD observation and record review, the licensee did not comply with the section cited above in that medication count for R1 not accurate, one tablet missing of Levothyroxine and one too many capsules of Florastor, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Facility to submit plan to conduct in-service and approved vendor medication training. Facility to complete training no later than 2/12/26. Facility to submit training log to CCL no later than 2/19/26. Training log to include hour of duration, time, date, instructor, and attendees.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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