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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803809
Report Date: 12/07/2021
Date Signed: 12/07/2021 05:39:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 VACAVILLEFACILITY NUMBER:
486803809
ADMINISTRATOR:STOUDER, ROBINFACILITY TYPE:
740
ADDRESS:799 YELLOWSTONE DRIVETELEPHONE:
(707) 447-7496
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:49CENSUS: 35DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Robin Stouder, AdministratorTIME COMPLETED:
05:49 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct a Required 1-Year Annual inspection and met with Executive Director, Robin Stouder (RS)(6047960740 expiration 4/2022) and Health and Wellness Director, Rosemarie Ferrer (RF). Today's inspection will focus on infection control. This facility has submitted a mitigation plan that was approved by the Department on 10/12/2021.

When LPA arrived at the facility they were greeted by staff, who checked LPA for symptoms and temperature via Accushield on an I PAD. There were posting at the entrance and throughout the facility to promote the prevention of COVID-19. The receptionist also request vaccination records of all visitors. There were multiple hand washing stations throughout the facility. There is an additional check-in station in the dinning room, where resident's temperatures are checked prior to dinning. Facility is disinfected multiple times throughout the day. LPA observed staff use disinfectant misters throughout the dinning room.

LPA toured the facility with RF. Facility buildings were found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. All staff and residents were wearing mask in the common areas. Facility has a 60+ day supply of personal protective equipment (PPE) and incontinence product. All staff have received infection control training. All staff and residents in assisted living have been vaccinated, and facility keeps a copy of all vaccination records on file. Facility has the capability of testing all residents on site and staff who may be experiencing symptoms. Facility staff monitor residents for change of conditions and input information in resident's daily log on staff IPADs. No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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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