486803808-4-17-2023-21-AS-ACAA-CPD2VQ-20230224164418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803808
Report Date: 02/24/2023
Date Signed: 04/17/2023 02:39:38 PM

Document Has Been Signed on 04/17/2023 02:39 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
CCLD Regional Office, 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: 38	DATE:	02/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Denise April Vasquez, Business Office Manager		TIME COMPLETED:	04:45 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	Licensing Program Analyst (LPA) Araceli Canela, arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Denise April Vasquez, Business Office Manager; Administrator, Kaitlyn Clarey was not available. 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 38 residents living in assisted living. There is an approved hospice waiver for six (6) residents. This facility has an independent section/apartments and the independent living is not licensed by Community Care licensing. LPA toured facility and grounds 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 states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation and infection control plan was submitted to the department. Caregivers have completed PPE training. 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 11/16/2022. Facility has hard wired smoke alarms and fire sprinklers that are serviced yearly. During today's inspection LPA found out there was an issue with a sprinkler or leak in the main entrance of the facility. LPA requested an incident report and additional information by 2/28/2023 for review. Facility provides activities for residents on a daily basis and residents are encouraged to attend. LPA observed several residents engaged and enjoying the activities.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: COGIR OF VALLEJO HILLS	FACILITY NUMBER: 486803808
	VISIT DATE: 02/24/2023

NARRATIVE

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LPA went over call buttons/pull cords for residents; who gets notified and provides assistance. LPA requested written plan on the operation of pull cords to be sent to LPA for review by 2/28/2023.

There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Kitchen observed clean, organized and staff wearing face covering. LPA went over dietary restrictions protocol.

LPA went over the following updated forms to be submitted to LPA A Canela by 3/24/2023.

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of Liability Insurance
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Denise Vasquez, Business Office Manager

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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