345002909-5-17-2022-25-AS-LMUN-CEHTD4-20220517143744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345002909
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:37:52 PM

Document Has Been Signed on 05/17/2022 02:37 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	COGIR OF FOLSOM		FACILITY NUMBER:	345002909
ADMINISTRATOR:	EKUNDARE, ADEBIMPE		FACILITY TYPE:	740
ADDRESS:	1801 EAST NATOMA STREET		TELEPHONE:	(916) 608-0800
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	66	CENSUS: 39	DATE:	05/17/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Adebimpe Ekundare		TIME COMPLETED:	02:47 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 (LPAs) Lavinia Muscan and Kerry Hiratsuka arrived at the facility unannounced to conduct an unannounced pre-licensing visit. This is a change of ownership. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk. LPA toured with Adebimpe Ekundare Executive Director. This building has 28 shared rooms and 10 private rooms. This facillity has delayed egress on all exit doors that residents can use to get outside as well as the gates for the courtyard that surrounds the back part of the building. There is an outside courtyard in the middle of the building that has no exit to the outside of the property. The doors leading to the courtyard have audio alerts. The courtyard has two water fountains that are placed in a permanent planter box that is roughly 12 inches higher than the ground. The fountains themselves are roughly two feet tall not including the planter box. The fountains are flat on top and are designed so the water does not pool on top and flows off the sides to the ground which is covered with large rocks that are spaced enough to let the water drain without pooling. The fountains do not cause any standing bodies of water. All doors to the rooms have key locks on them and all staff have a master key for the resident rooms. Each room has a motion sensor in the middle of the room, a pull cord for each bed, one for the bathroom, and a call button on the wall. The rooms have a drawer with a lock for the resident's use in the closet. All private rooms have bathrooms with showers and about half of the shared rooms have bathrooms with showers. The rest of the shared rooms have half bathrooms. There are four common full bathrooms; two have only showers and two have only spa tubs. There are two dining areas and two television rooms. There are several smaller activity areas and two sitting areas at the end of two hallways. All maintenance closets are locked.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COGIR OF FOLSOM	FACILITY NUMBER: 345002909
	VISIT DATE: 05/17/2022

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There are several staff offices throughout the building. There's a health station to the left of the entrance to the resident's living area. This has the medication room behind it and the room is locked when no one is in there. The kitchen area is locked. Both dining rooms have small kitchenettes that have an oven and sink. The oven door has a lock and the oven itself has a secured shut off to prevent it from working when not in use. There is a front lobby that has a sitting area and a conference room to the left. This connects to the resident area through a secured door. Several resident rooms were inspected during this visit.

LPA waived Comp III because Executive Director has worked at other facilities and the Applicant operates other facilities. .

Several topics were discussed.
This facility meets licensing requirements. LPA is going to submit this to applications specialist.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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