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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002909
Report Date: 06/21/2024
Date Signed: 06/21/2024 01:25:02 PM


Document Has Been Signed on 06/21/2024 01:25 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
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: 22DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Davina BarkerTIME COMPLETED:
01:25 PM
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On 6/21/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Executive Director, Davina Barker, and explained the purpose of the visit.

Today's census is 22 residents with eight (8) residents on hospice services. Facility is licensed for 66 residents, hospice waiver of 16.

Executive Director reported no staffing concerns. LPA was informed there are three care staff and one med tech for AM and PM shift and with two care staff for NOC shift.

LPA and Executive Director conducted a tour the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: five residents bedroom, Tahoe Room, main dining, kitchen, laundry room, activity room and the common areas. LPA observed facility to have 2+ days of perishable and 7+ days of non-perishable foods. LPA observed the facility to be at a comfortable 72* degree. LPA observed facility to have ample supply of linens. LPA observed residents in care to be in the activity room, listening to music with care staff. During today's visit, LPA observed facility to be clean, sanitary and in good repair.

File review was conducted for 5 residents and 5 personnel files. LPA observed files to be completed. Inspection tool completed and found facility to be in substantial compliance. No deficiencies cited.

LPA observed facility liability insurance to be current and active.

Exit interview conducted and a copy of report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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