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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486803808
Report Date:
01/13/2024
Date Signed:
01/13/2024 12:42:07 PM
Document Has Been Signed on
01/13/2024 12:42 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:
CLAREY, KAITLYN
FACILITY TYPE:
740
ADDRESS:
350 LOCUST DRIVE
TELEPHONE:
(707) 266-6822
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94591
CAPACITY:
80
CENSUS:
36
DATE:
01/13/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Susan Allen
TIME COMPLETED:
12:50 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Facility Chef Saverio Gratteri. Executive Director Susan Allen showed up and completed the visit.
This facility is connected to three other buildings for a total of four buildings connected by walkways. The other three buildings are independent senior living communities not under the jurisdiction of Community Care Licensing Division (CCLD). The building that is licensed has three floors. Each apartment has a kitchenette and a full bathroom. LPA toured seven apartments and no concerns were found. There are common areas on each floor.
During today's visit LPA observed the following which is not a safety concern to the residents:
-one wing which has four apartments is sealed off because the building had a plumbing issue and in order to reach the pipes the floors in that area had to be taken out. The resident affected were relocated to empty apartments and the wing is sealed off for safety reasons. LPA was informed the construction is almost complete.
The following shall be updated and submitted to CCLD by 02/10/2024:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-paperwork appointing current executive director
-liability insurance
LPA obtained updated contact information.
Multiple topics were discussed
No deficiencies cited.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
01/13/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/13/2024
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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