486803808-2-12-2026-21-AS-CFES-DR92HN-20260212162501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803808
Report Date: 02/12/2026
Date Signed: 02/12/2026 04:25:09 PM

Document Has Been Signed on 02/12/2026 04:25 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	COGIR OF VALLEJO HILLS		FACILITY NUMBER:	486803808
ADMINISTRATOR/ DIRECTOR:	BARAJAS, JOSE		FACILITY TYPE:	740
ADDRESS:	350 LOCUST DRIVE		TELEPHONE:	(707) 553-2698
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 80		CENSUS: 166	DATE:	02/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Business Office Manager, Denise Vasquez, Health and Wellness Director, Allison Mendoza, and Davina Barker, Regional Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:35 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	At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Business Office Manager, Denise Vasquez. Health and Wellness Director, Allison Mendoza, arrived during visit at approximately 9:30AM. Davina Barker, Regional Executive Director, arrived during visit at approximately 11:15AM. Facility is a Residential Care Facility for the Elderly (RCFE) and provides care and assistance to older adults. Facility has an approved fire clearance and capacity for 80 non-ambulatory residents and has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 166 residents in care with 52 residents in Assisted Living and 114 residents in Independent Living. LPA was also informed that there were 66 staff members on-site. LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed a sample size of 5 staff files and 5 resident files. Files were all found to be well organized, thorough, and contained the required documentation. Staff files had current First Aid and/or CPR certification and required annual training. Resident files were found to have updated resident assessments and appraisals. Facility's fire alarms were last inspected July 2025, facility's sprinkler systems were last inspected June 2026 and facility's fire extinguishers were last inspected December 2025. Facility's last emergency/disaster drill was December 2025. LPA discussed the following topics with Health and Wellness Director and Regional Executive Director: Reporting Requirements , PIN regarding 911 protocols, and Physician Reports (LIC602). During visit, LPA was informed that Administrator/Executive Director, Jose Barajas, was no longer at the facility and that Health and Wellness Director, Allison Mendoza, will be submitting their paperwork for Change of Administrator. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF VALLEJO HILLS	FACILITY NUMBER: 486803808
	VISIT DATE: 02/12/2026

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
26
27
28
29
30
31
32

Continued from LIC809

LPA requested for the following documents to be submitted to Community Care Licensing (CCL) by 02/27/2026 for processing.

Administrator Documents:
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· LIC215 (Applicant Information)
· Proof of Negative TB test
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Requested Documents to update facility file:
· Emergency Disaster Plan (LIC 610E)
· Updated Liability Insurance
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property
Documents to be submitted to Community Care Licensing (CCL) by due date of 03/12/2026.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3