486803808-2-19-2025-21-AS-RFRK-DE2V8M-20250219151257

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803808
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:13:16 PM

Document Has Been Signed on 02/19/2025 03:13 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:	CLAREY, KAITLYN		FACILITY TYPE:	740
ADDRESS:	350 LOCUST DRIVE		TELEPHONE:	(707) 553-2698
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 80	TOTAL ENROLLED CHILDREN: 0	CENSUS: 42	DATE:	02/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Susan Allen, Acting Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:25 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 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Susan Allen. Facility provides care and assistance to Older Adults in Assisted Living.. Fire clearance is approved for eighty (80) non-ambulatory residents. There is an approved hospice waiver for six (6) residents. The community consists of four buildings that are connected via walkways. One (1) building consists of assisted living. The other three (3) buildings are for independent senior living. The independent living buildings are not part of the Residential Care for the Elderly (RCFE) license. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Upon arrival, LPA was informed that there were 42 residents in care. At approximately 9:30 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:20 AM LPA toured the facility with ED Allen. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offered a variety of menu options for the residents at each meal. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of seven (7) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. The call system was tested in two (2) resident's rooms and Caregiver response time was under one (1) minute for both instances. Continued on 809-C

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Robert Frank	TELEPHONE: (707) 588-5026
	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF VALLEJO HILLS	FACILITY NUMBER: 486803808
	VISIT DATE: 02/19/2025

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...Continued from 809

Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 9/2024. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged 1/20/2025. The Vallejo Fire Department inspected the facility on 4/30/2024 and issued no citations. The facility completes fire/emergency drills quarterly.

LPA conducted a sample file review of eight (8) staff members. All staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for eight (8) residents. Upon review, LPA observed residents to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to residents in care. LPA conducted a spot check of five (5) residents’ medications and observed medications to be centrally stored and all documentation and medications to be in order.

During the tour, residents were observed interacting with staff in common spaces, resting in their private apartments, participating in various activities and mingling amongst each other. The facility provides an eclectic range of activities for it's residents in assisted living. The facility has a hair salon, library and a country store. Computers are available for residents' use in the Library.

Susan Allen’s Administrator Certification 6012927740 is current with an expiration date of 4/4/2026.

LPA is requesting the following documents submitted to CCLD by 3/19/2025:

LIC 500 - Personnel Report
LIC 610E-Emergency Disaster Plan
Copy of Current Liability Insurance

No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Allen. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert Frank	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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