<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 01/14/2025
Date Signed: 01/14/2025 05:07:44 PM

Document Has Been Signed on 01/14/2025 05:07 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/
DIRECTOR:		GACEGU, MONICAHFACILITY TYPE:
740
ADDRESS:6299 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7884
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 8CENSUS: 7DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:58 PM
MET WITH:Monicah Gacegu-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year inspection, at approximately 3:58pm on 1/14/25, and met with Administrator Monicah Gacegu. LPA observed a caregiver, Jane Mburu, on duty during the inspection.

Caregiver Jane has a criminal record clearance as required, and is associated to the facility.

There are currently seven (7) residents in care. The facility is fire cleared for eight (8) non-ambulatory residents. Hospice waiver is approved for three (3) residents. The facility has an approved dementia plan of operation. The facility has a required infection control plan and a required emergency disaster plan.

LPA observed some residents in the living room watching television, and other residents were in their private rooms. Staff was preparing the dinner meal for the residents in care.

The LPA will continue this annual inspection at a later date.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 1