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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002909
Report Date: 07/25/2024
Date Signed: 07/25/2024 11:59:18 AM


Document Has Been Signed on 07/25/2024 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:DAVINA BARKERFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 27DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Deborah Taylor and Davina BarkerTIME COMPLETED:
12:00 PM
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On 7/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the LIC 624 Unusual Incident/Injury Report the Department received. LPA met with new Executive Director, Deborah Taylor, and Regional Director, Davina Barker, and explained the purpose of the visit.

The incident occurred when R1 was eating lunch in the common dining room when S1 observed R1 to be choking. S2 then helped dislodged meat out of R1's throat. R1 was sent out for evaluation. Incident report stated primary care physician was notified. R1 returned to the facility with no changes.

LPA and Regional Director discussed and confirmed that R1's responsible party was notified via "voice to voice". It was further discussed that R1 was not on special diet but after the incident, R1 is now on a new order of mechanical soft diet.

Facility reported no staffing issues and/or additional concerns.

As a result of today's visit, no deficiencies cited.

Exit interview conducted an a copy of the report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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