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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:46:28 PM

Document Has Been Signed on 02/19/2025 04:46 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:
02/19/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Monicah Gacegu-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alviso and Contreras arrived unannounced to conduct a Required -1 Year inspection, on 2/19/25 at approximately 12:20pm, and met with caregivers Ann and Fredah. Staff contacted Administrator Monicah Gacegu and notified them the LPAs were at the facility. The Administrator arrived to meet with the LPAs.

Fire clearance is approved for eight (8) non-ambulatory only. There were seven (7) residents in care at the facility during the inspection. `
Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. The facility has a required infection control plan. The facility has a required emergency and disaster plan.
LPAs reviewed seven (7) resident files, including storage of medications and medication records.
LPAs reviewed three (3) staff files, including training. All staff have required criminal record clearance.

LPAs toured the facility with the caregiver Fredah; LPAs toured the facility with the Administrator when they arrived. LPAs observed cleaners/disinfectants locked and inaccessible to residents in care. All medications were locked and inaccessible to residents in care. All exits were free and clear of obstructions. There was a sufficient supply of perishable and non-perishable food. There was a sufficient supply of hygiene products, linens, paper products, and personal protective equipment (PPE) for use as needed. Carbon monoxide detector was working properly during the inspection. All resident rooms and common areas had required smoke alarms. Fire extinguishers was serviced and tagged as required. There was sufficient lighting in the resident rooms, bathrooms, and all common areas.

LPA is requesting the following documents be updated and submitted by 3/19/25:


LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan- review and if no changes, submit a copy of last page w/signature & Date. If changes, submit a copy of the plan.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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 5
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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853
VISIT DATE: 02/19/2025
NARRATIVE
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Infection Control Plan-review and if no changes, submit a statement w/signature & Date. If changes, submit a copy of the plan.
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond if handling cash..
Copy of Current Liability Insurance
Copy of current Administrator Certificate

The following deficiencies were observed by the LPAs:
LPAs checked the hallway resident bathroom's hot water, and it was checked at 169.9 degrees Fahrenheit; This is not within regulation of no lower than 105. degrees or no higher than 120. degrees Fahrenheit. This deficiency will be cited, Maintenance and Operation Section 87303(e)(2) - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

LPAs observed an area where it is filled with various size rocks, and it was flooded making it a small pond/small water feature. Water was no longer draining out of this rock filled area. This has never been observed this way prior to today's inspection. The water is at a level where it may be a risk to the health & safety of residents in care. This will be cited, Personal Accommodations and Services 87307(f)-The licensee shall supervise residents as needed and as determined by the resident's appraisal, pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to birdbaths, fountains, or similar smaller decorative water features. This will be cited,

Per review of records, Administrator could not provide proof of having completed emergency disaster quarterly drills as required. This deficiency will be cited, Emergency Plans HSC 1569.695(c) - A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.



Exit interview conducted with Administrator Monicah Gacegu. Appeal rights were provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/19/2025 04:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/19/2025 at 04:06 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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record reviews, and interviews, Administrator could not provide proof of having completed emergency disaster quarterly drills as required, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee/Administrator to submit plan of correction to ensure the facility is/will conduct the required quarterly drills. Submit a completed quarterly drill with all staff, include all required documentation of the drill. Submit plan of required future annual drills to be completed as required. POC due 2/28/2025.
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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/19/2025 04:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/19/2025 at 04:15 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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation Section 87303(e)(2) - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs checked the hallway resident bathroom's hot water, and it was checked at 169.9 degrees Fahrenheit; This is not within regulation of no lower than 105. Degrees Fahrenheit or no higher than 120. degrees Fahrenheit., the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Licensee/Administrator turned down the hot water heater. Licensee will ensure the hot water is no lower than 105. degrees Fahrenheit and no higher than 120 degrees Fahrenheit. Submit a copy of the hot water check log of five days, 2/25/25, ensuring it is within compliance. POC due 2/20/2025.
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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/19/2025 04:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/19/2025 at 04:21 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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(f)
Personal Accommodations and Services 87307(f) -The licensee shall supervise residents as needed and as determined by the resident's appraisal, pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to birdbaths, fountains, or similar smaller decorative water features.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed an area in the backyard where it is filled with various size rocks, and it was flooded making it a small pond/water feature. Water was no longer draining out of this rock filled area. This has never been observed this way prior to today's inspection. The water is at a level where it may be a risk to the health & safety of residents in care.], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Licensee/Administrator to ensure that all staff are monitoring residents as needed and redirecting residents as needed to ensure their needs are met regarding keeping the backyard rock filled water small (pond liike) water feature. Administrator stated they will unclog this area and drain it as needed, it is not meant to be a water feature. Submit plan of ensuring residents health & safety regarding the above, and plan of correction. POC due by 2/20/25.
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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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