Inspection Reports for Cogir of Sonoma
800 Oregon St, Sonoma, CA 95476, United States, CA, 95476
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and compliant with infection control and medication storage standards. The most recent report from July 23, 2025, had no deficiencies but substantiated a complaint about a resident with dementia leaving unassisted; the facility responded by providing a companion and transferring the resident to a Memory Care unit. Earlier reports identified some deficiencies related to incomplete resident records and staff health screenings, as well as medication record errors, but these were addressed with plans of correction. Several complaint investigations were unsubstantiated, including allegations about medication assistance and unsafe chemical use. The facility’s record shows improvement over time, with recent inspections consistently free of deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 28
Capacity: 82
Deficiencies: 0
Jul 23, 2025
Visit Reason
The inspection was an unannounced case management visit triggered by an incident report regarding a resident (R1) who exited the community unassisted on 06/07/2025.
Findings
The investigation found that the resident with dementia exited the facility unassisted, despite no prior history of wandering or elopement. The facility responded by providing a companion and eventually transferring the resident to a Memory Care unit. No deficiencies were cited during the inspection.
Complaint Details
The complaint involved an incident of elopement by resident R1 on 06/07/2025. The incident was substantiated as the resident left unassisted, but the facility took corrective actions including notifying family and physician, providing a companion, and transferring the resident to a Memory Care unit. The administrator disagreed with the physician's assessment that the resident should not leave unassisted, believing the incident was due to dementia progression rather than lack of supervision.
Report Facts
Incident date: Jun 7, 2025
Incident report submission date: Jun 16, 2025
Resident transfer date: Jun 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed incident report and care plans |
| Rose Lazzarotto | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Rafael Mendoza | Administrator | Available by phone during inspection and discussed incident and corrective actions |
| Norma Alvarez | Health and Wellness Director | Notified family and physician of resident elopement |
Inspection Report
Annual Inspection
Census: 26
Capacity: 82
Deficiencies: 0
Jan 13, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean and well-maintained with no deficiencies noted in resident or staff records, medication storage, or infection control plans. Minor water temperature adjustment was agreed upon to meet regulatory standards.
Report Facts
Water temperature readings: 121.2
Fire extinguisher last inspection date: Jan 9, 2025
Smoke/Carbon Monoxide detector last service date: Aug 26, 2024
Quarterly disaster drill date: Dec 13, 2024
Elevator last service date: Mar 15, 2024
Resident records reviewed: 5
Staff records reviewed: 5
Days supply of perishable food: 2
Days supply of non-perishable food: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rafael Mendoza | Administrator | Met with Licensing Program Analyst during inspection and involved in facility tour and discussions |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 23
Capacity: 82
Deficiencies: 3
Jan 26, 2024
Visit Reason
The inspection visit was an unannounced continuation of the required annual case management inspection to evaluate compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including incomplete or outdated tuberculosis (TB) screening and health screenings for staff, incorrect medication expiration and fill dates in resident medication records, and missing TB screening or medical assessment documentation for residents. Plans of correction were requested for these deficiencies.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff files lacked clear TB or chest x-ray results and health screenings were outdated beyond six months prior to employment. | Type A |
| Resident medication records had incorrect expiration and fill dates entered on the CSML for certain prescriptions. | Type B |
| Resident file lacked TB screening or results; chest x-ray did not mention negative TB or evidence of TB. | Type B |
Report Facts
Residents on hospice: 3
Staff files reviewed: 5
Resident files reviewed: 5
Plan of Correction Due Date: Feb 9, 2024
Plan of Correction Due Date: Jan 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rafael Mendoza | Administrator | Met with Licensing Program Analyst during inspection; involved in discussion of infection control plan and staff TB screening plan. |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection, reviewed staff and resident files, observed medication administration, and documented deficiencies. |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection and deficiency citations. |
Inspection Report
Annual Inspection
Census: 23
Capacity: 82
Deficiencies: 0
Jan 24, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and in compliance with regulations. No deficiencies were cited during the visit, though the annual inspection was not completed and will be continued at a later date.
Report Facts
Residents on hospice: 3
Fire extinguisher last inspection date: Feb 10, 2023
Fire system last service date: Feb 23, 2023
Last quarterly disaster drill date: Nov 29, 2023
Water temperature range (degrees F): Water temperature measured at 113.2 and 117.2 degrees F, within allowable range of 105 to 120 degrees F
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rafael Mendoza | Administrator | Met with Licensing Program Analyst during inspection |
| Christi Coppo | Licensing Program Analyst | Conducted the annual inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Census: 26
Capacity: 45
Deficiencies: 0
Jul 6, 2023
Visit Reason
The visit was an unannounced Case Management - Other inspection conducted to amend a prior Complaint Investigation Inspection Report dated June 20, 2023.
Findings
No deficiencies were cited during this Case Management-Other inspection. The Licensing Program Analyst educated facility staff on the importance of conducting resident reappraisals as required by regulation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Omar Mendoza | Interim Administrator | Met with Licensing Program Analyst during inspection. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and education on reappraisals. |
| Hope DeBenedetti | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 45
Deficiencies: 1
Jun 20, 2023
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff did not provide proper medication assistance to a resident and that a resident had access to centrally stored medications.
Findings
The complaint allegations regarding improper medication assistance and resident access to centrally stored medications were found to be unsubstantiated due to inconsistent statements and lack of corroborating evidence. However, a deficiency was substantiated related to incomplete resident records, including missing medical assessment reports and reappraisals.
Complaint Details
Complaint allegations included staff not providing proper medication assistance and resident access to centrally stored medications. These allegations were unsubstantiated after investigation due to inconsistent statements and lack of evidence. However, a complaint alleging improper maintenance of resident records was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident records were incomplete and missing LIC 602 and Resident Reappraisals paperwork; Resident #1 did not receive a reappraisal in 2022. | Type B |
Report Facts
Capacity: 45
Census: 26
Plan of Correction Due Date: Jun 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Omar Mendoza | Interim Administrator | Met with Licensing Program Analyst during investigation |
| Matthew Horstmann | Administrator | Facility administrator named in the report |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 26
Capacity: 45
Deficiencies: 0
Jan 31, 2023
Visit Reason
The inspection was a Required-1 Year unannounced inspection focused on infection control practices and procedures at the facility.
Findings
The facility was found to be clean and in good repair with clear exits and walkways. Infection control measures were in place, including visitor and staff screening, sufficient PPE, staff training, and vaccination. No deficiencies were cited during the inspection.
Report Facts
Days to submit requested documents: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Horstmann | Administrator | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Census: 30
Capacity: 45
Deficiencies: 0
Oct 5, 2022
Visit Reason
The visit was an unannounced case management incident review to discuss reported incidents for 2022 and assess compliance.
Findings
The facility reported only one incident in 2022, and no other reportable incidents were found during interviews. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Horstmann | Executive Director | Met during the case management visit and discussed incident reports. |
| Katrina Walters | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 45
Deficiencies: 0
Mar 2, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that the facility does not provide a safe environment for residents due to spraying toxic chemicals inside the facility.
Findings
The investigation found that fragrance oil dispensers were used throughout the facility, releasing fragrance on timed intervals. The fragrance oil bottle was unlabeled but a safety data sheet was provided indicating the material does not present a hazard if inhaled or require special cleanup. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged the facility sprayed toxic chemicals inside the facility creating an unsafe environment. The allegation was unsubstantiated after investigation including observations, interviews, and document review.
Report Facts
Capacity: 45
Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Matthew Horstmann | Administrator | Facility administrator met during the investigation |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 31
Capacity: 45
Deficiencies: 0
Dec 9, 2021
Visit Reason
The inspection was an unannounced Required – 1 Year inspection conducted to evaluate compliance with licensing regulations for the assisted living facility.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control measures including PPE use and vaccination rates. No deficiencies were cited during the inspection.
Report Facts
Capacity: 45
Census: 31
Vaccination rate: 100
Fire extinguisher inspection date: Jan 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Horstmann | Administrator | Met with Licensing Program Analyst during inspection |
| Norma Alvarez | Health/Wellness Director | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection |
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