Inspection Reports for
Cogir of Sonoma
800 Oregon St, Sonoma, CA 95476, United States, CA, 95476
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
34% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Capacity: 82
Deficiencies: 1
Date: Jan 29, 2026
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements for the assisted living facility.
Findings
The facility was found to be clean, well-maintained, and compliant with food storage and water temperature regulations. However, two medication errors were observed involving inaccurate medication counts for one resident, posing an immediate health and safety risk.
Deficiencies (1)
Medication count for resident (R1) was inaccurate with one tablet of Levothyroxine missing and one extra capsule of Florastor, posing an immediate health, safety, or personal rights risk.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 7
Medication errors observed: 2
Facility capacity: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rafael Mendoza | Administrator | Met with Licensing Program Analyst during inspection and involved in review of facility conditions and plans |
| Christi Coppo | Licensing Program Analyst | Conducted the annual inspection and documented findings |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
| Health and Wellness Director | Assisted in medication and medication records spot check |
Inspection Report
Census: 28
Capacity: 82
Deficiencies: 0
Date: Jul 23, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted due to an incident report submitted by the facility regarding a resident who exited the community unassisted.
Findings
The inspection found that the resident with dementia exited the facility unassisted but no deficiency was cited. The administrator and licensing analyst discussed reviewing all residents' physician reports for discrepancies and agreed on immediate correction if needed.
Report Facts
Incident date: Jun 7, 2025
Resident move date: Jun 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the case management inspection |
| Rafael Mendoza | Administrator | Facility administrator involved in incident discussion |
| Rose Lazzarotto | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Norma Alvarez | Health and Wellness Director | Notified family and physician of resident elopement |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 82
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Jan 13, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analyst Christi Coppo to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean and well-maintained with proper food storage and safety measures. Resident rooms and safety equipment were inspected with minor water temperature adjustment recommended. Reviews of resident and staff records, medication storage, infection control, and emergency plans revealed no deficiencies. No deficiencies were cited during the inspection.
Report Facts
Water temperature: 121.2
Fire extinguisher last inspection date: Jan 9, 2025
Smoke/Carbon Monoxide detector last service date: Aug 26, 2024
Disaster drill date: Dec 13, 2024
Elevator last service date: Mar 15, 2024
Number of resident records reviewed: 5
Number of staff records reviewed: 5
Number of water heaters: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rafael Mendoza | Administrator | Met with Licensing Program Analyst during inspection; named in report |
| Christi Coppo | Licensing Program Analyst | Conducted the annual inspection |
| Victoria Bertozzi | Supervisor | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 26
Capacity: 82
Deficiencies: 0
Date: 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
Date: Jan 26, 2024
Visit Reason
The inspection 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 record entries for residents, and missing TB screening or medical assessment documentation for residents. Plans of correction were requested for these deficiencies.
Deficiencies (3)
Staff files lacked clear TB or chest x-ray results and health screenings were outdated beyond six months prior to employment.
Resident medication records had incorrect expiration and fill dates entered on the Controlled Substance Medication List (CSML).
Resident R2 did not have a TB screen or results in their file; chest x-ray present but no evidence of TB status.
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; named in report. |
Inspection Report
Annual Inspection
Census: 23
Capacity: 82
Deficiencies: 3
Date: 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.
Deficiencies (3)
Staff files lacked clear TB or chest x-ray results and health screenings were outdated beyond six months prior to employment.
Resident medication records had incorrect expiration and fill dates entered on the CSML for certain prescriptions.
Resident file lacked TB screening or results; chest x-ray did not mention negative TB or evidence of TB.
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
Date: Jan 24, 2024
Visit Reason
The visit was an unannounced required annual inspection 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, but 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 test/service date: Feb 23, 2023
Last quarterly disaster drill date: Nov 29, 2023
Water temperature range: 113.2 to 117.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rafael Mendoza | Administrator | Facility Administrator who met with Licensing Program Analyst during inspection |
| Christi Coppo | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Annual Inspection
Census: 23
Capacity: 82
Deficiencies: 0
Date: 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
Date: Jul 6, 2023
Visit Reason
Licensing Program Analyst arrived unannounced to amend a prior Complaint Investigation Inspection Report dated June 20, 2023.
Findings
No deficiencies were cited during this Case Management-Other inspection. The analyst educated facility staff on the importance of conducting resident reappraisals as required by regulation.
Report Facts
Resident #1 reappraisal year: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and education on reappraisals |
| Omar Mendoza | Interim Administrator | Met Licensing Program Analyst and granted access to the facility |
Inspection Report
Census: 26
Capacity: 45
Deficiencies: 0
Date: 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
Date: Jun 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not provide proper medication assistance to a resident and that a resident had access to centrally stored medications. An amended complaint also alleged that staff did not properly maintain resident records.
Complaint Details
The complaint investigation was unannounced and conducted due to allegations of improper medication assistance and resident access to medications, as well as improper maintenance of resident records. The medication-related allegations were unsubstantiated, while the record maintenance allegation was substantiated.
Findings
The allegation regarding improper medication assistance and resident access to centrally stored medications was unsubstantiated due to inconsistent statements and lack of corroborating evidence. However, the allegation that staff did not properly maintain resident records was substantiated, with observations showing incomplete resident records missing required paperwork and a resident not reappraised in 2022.
Deficiencies (1)
Resident records were incomplete and missing LIC 602 and Resident Reappraisals paperwork; Resident #1 was not reappraised in 2022.
Report Facts
Capacity: 45
Census: 26
Deficiencies cited: 1
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 | Facility representative who met with the evaluator during the investigation |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 45
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Resident records were incomplete and missing LIC 602 and Resident Reappraisals paperwork; Resident #1 did not receive a reappraisal in 2022.
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
Date: 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 adequate, including screening, PPE availability, staff training, and vaccination status. No deficiencies were cited during the inspection.
Report Facts
Capacity: 45
Census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection and met with the administrator |
| Matthew Horstmann | Administrator | Facility administrator met during inspection |
Inspection Report
Annual Inspection
Census: 26
Capacity: 45
Deficiencies: 0
Date: 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
Date: Oct 5, 2022
Visit Reason
The visit was an unannounced case management visit to review incident reports for 2022 and assess any reportable incidents within the facility.
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 with Licensing Program Analyst during the case management visit. |
| Katrina Walters | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Census: 30
Capacity: 45
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
The complaint alleged that the facility sprays toxic chemicals inside the facility creating an unsafe environment. The allegation was unsubstantiated after investigation.
Findings
The investigation found that fragrance oil dispensers periodically release fragrance throughout the facility. 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 procedures. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 45
Census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the complaint investigation |
| Matthew Horstmann | Administrator | Facility administrator met during investigation |
| Kimberley Mota | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 45
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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
Fire extinguisher inspection date: Jan 22, 2021
Vaccination rate: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Horstmann | Administrator | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection |
| Norma Alvarez | Health/Wellness Director | Accompanied the Licensing Program Analyst during facility tour |
Inspection Report
Annual Inspection
Census: 31
Capacity: 45
Deficiencies: 0
Date: 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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