486803808-1-4-2024-21-AS-VBEI-CZTUJU-20240125143807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803808
Report Date: 01/04/2024
Date Signed: 01/04/2024 08:21:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2023 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20231229150011

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:	01/04/2024
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Susan Allen, Administrator/Executive Director		TIME COMPLETED:	04:08 PM

ALLEGATION(S):

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Uncleared adult has access to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of opening a complaint investigation, regarding the above listed allegation. LPA met with Executive Director, Susan Allen, toured all three floors of assisted living facility, made observations and took statements.

It was alleged there is an uncleared adult who has access to residents in care.
Investigation revealed staff S1 went through the required fingerprint process and associated to this facility, but S1's clearance was not granted by the department and S1 was placed under pending status; meaning that S1 was not cleared to work or be in this facility until proper clearance was granted. The facility allowed S1 to be in the facilities assisted living area by hiring S1 as an outside contractor when clearance was in pending status.

Continue report see LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231229150011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/04/2024

NARRATIVE

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Continue report from LIC9099

Interviews conducted revealed S1 had access and was in the licensed part of this facility providing the same work as other facility maintenance staff.

A $100.00 civil penalty was assessed on todays date for uncleared adult S1.

Allegation, Uncleared adult has access to residents in care, is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231229150011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/05/2024 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	87355(e)(1)Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to Health & Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.	1 2 3 4 5 6 7	Facility to submit a written plan that they understand regulation and how it will maintain compliance. Facility also informed LPA S1 would not be in the facility
	8 9 10 11 12 13 14	This requirement was not met, As evidenced by: Complaint investigation revealed staff S1 did not have the proper fingerprint clearance & had access to residents in care. This is an immediate risk to the Health & safety of residents in care.	8 9 10 11 12 13 14	until S1 received the proper clearance or received a criminal exemption. Written plan POC due 1/5/2024 A civil penalty of $100.00 was applied for uncleared adult.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC9099 (FAS) - (06/04)

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