486803809-11-22-2021-21-AS-KMOA-C92RG4-20211123120008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803809
Report Date: 11/22/2021
Date Signed: 11/22/2021 12:13:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20211116082746

FACILITY NAME:	COGIR OF VACAVILLE		FACILITY NUMBER:	486803809
ADMINISTRATOR:	STOUDER, ROBIN		FACILITY TYPE:	740
ADDRESS:	799 YELLOWSTONE DRIVE		TELEPHONE:	(707) 447-7496
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	49	CENSUS: 32	DATE:	11/22/2021
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Administrator, Robin Stouder		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff not providing adequate food service for residents
Staff deny resident with more food servings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cogir of Vacaville. LPA met with and was granted access into the facility by Business Services Officer, Jan Zawadski. Administrator, Robin Stouder arrived 5 minutes later from walking the facility grounds. During the complaint, LPA toured the facility kitchen, obtained facility menu, obtained alternate menu, LIC 500 and roster for Independent Living and Assisted Living residents.

LPA observed during facility tour on 11/22/2021, all allegations listed in the complaint are located on the Independent Living (IL) portion of the facility. Community Care Licensing (CCL) does not have jurisdiction to enforce regulations on that portion of the facility. Based on the investigation, LPA was unable to identify any deficiencies regarding food service for the Assisted Living (AL) side of the facility that CCL does have jurisdiction. In addition, LPA toured the facility kitchen and found food stored in the kitchen were properly stored as per regulations on this day at the time of the tour of the kitchen. (Report continued on LIC 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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-20211116082746

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: COGIR OF VACAVILLE	FACILITY NUMBER: 486803809
	VISIT DATE: 11/22/2021

NARRATIVE

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This agency has investigated the complaint allegations of Staff not providing adequate food service for residents and staff deny residents with more food servings. After interview and observations, we have found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were observed or cited during today’s complaint investigation inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC9099 (FAS) - (06/04)

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