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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803809
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:47:58 PM


Document Has Been Signed on 09/15/2022 04:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: DATE:
09/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Robin StouderTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Walters arrived unannounced to follow up on a self-reported incident 9/7/22. LPA was greeted by Administrator, Robin Stouder.

The facility self-reported an incident occurring 9/6/22 involving R1, in which R1 left the facility. Per interviews Staff attempted to locate R1 immediately after learning they were not in the facility. Staff found resident in the parking lot of the facility in need of medical assistance. Staff S1 and S2 immediately called emergency services. LPA reviewed R1's medical records. R1 did not have a dementia diagnosis. LPA conducted interviews and made observations. LPA requested additional information from Administrator.

Nothing further.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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