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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803808
Report Date: 12/15/2021
Date Signed: 12/16/2021 02:56:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:COGIR OF VALLEJO HILLSFACILITY NUMBER:
486803808
ADMINISTRATOR:DOWELL, CAROLFACILITY TYPE:
740
ADDRESS:350 LOCUST DRIVETELEPHONE:
(707) 266-6822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:80CENSUS: 36DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Carol DowellTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Araceli Canela, arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Administrator, Carol Dowell. The annual inspection is focused on the Infection Control procedures and practices of this facility.

This facility is licensed to care for up to 80 non-ambulatory residents, at this time the facility has 36 residents living in assisted living. There is an approved hospice waiver for six (6) residents. LPA toured facility and grounds with administrator and observed COVID-19 precaution signs posted in common areas and bathrooms to promote physical distancing, face coverings and hand washing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility follows indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Facility states staff clean and disinfect the facility daily. Facility understands hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was submitted to the department on 7/20/2021. Caregivers have completed PPE training but have and have been N-95 Fit tested. Lap observed hand sanitizers throughout facility.
In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be charged and serviced 11/4/2021. Facility has hard wired smoke alarms and fire sprinklers that are serviced yearly. Smoke and Carbon monoxide detectors were fully operational. At time of inspection, there was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Kitchen observed clean and organized and staff wearing face covering.

No citations issued during todays visit, this report emailed to facility due to printer issues.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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