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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803808
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:35:36 AM


Document Has Been Signed on 08/31/2023 11:35 AM - 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 HILLSFACILITY NUMBER:
486803808
ADMINISTRATOR:CLAREY, KAITLYNFACILITY TYPE:
740
ADDRESS:350 LOCUST DRIVETELEPHONE:
(707) 266-6822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:80CENSUS: 41DATE:
08/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Susan AllenTIME COMPLETED:
12:00 PM
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Licensing Program Analyst arrived unannounced for the purpose of following up on a death report received for resident R-1 who died on July 08, 2023. LPA toured portions of the facility and spoke with the Administrator. LPA obtained medical records for the deceased resident and requested additional records which will be forwarded to LPA by the Administrator. Although R1 resided at the facility, death occurred at a medical facility in Vallejo.

No citations issued today.
Report left.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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