486803809-1-27-2023-21-AS-KWAS-CNGRGQ-20230127120108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803809
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:02:15 PM

Document Has Been Signed on 01/27/2023 12:02 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 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: 34	DATE:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Robin Stouder		TIME COMPLETED:	12:15 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	Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct an Annual Required inspection and met with Health and Wellness Director, Rosemarie Ferrer and Executive Director, Robin Stouder. This facility currently is licensed for 49 assisted living residents, and there are currently 34 assisted living residents residing in the facility. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. The facility submitted their infection control plan and addendum to Community Care Licensing, which has been approved. Upon entering the facility there is signage directing visitors to wear a mask prior to entering. Visitors are screened for COVID-19 symptoms at the receptionist desk before moving throughout the facility. The screening is completed on a computer screen and includes a questionnaire and temperature check. There is hand sanitizer and disposable mask available for visitors at the entrance. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. Signs are also posted in the elevator to encourage distancing. Administrator stated staff clean and disinfect the facility daily and on each shift. High touched surface areas are disinfected after each use. The facility has a designated visitation area and allows visitors to visit in resident's studios. Prior to entering the dining area the hostess checks all of the residents temperatures. Activities have been altered to ensure distancing and droplet precautions. Activities such as "Sittercise, Pinochle and Rummikub" were scheduled for residents. Continued on 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF VACAVILLE	FACILITY NUMBER: 486803809
	VISIT DATE: 01/27/2023

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Continued from 809

All staff have received N-95 respirator Fit testing. LPA observed an ample supply of PPE products including gloves, face shields, N-95 respirators, surgical masks, and gowns. All staff wore a face mask during this visit. Facility keeps inventory of of PPE. LPA reviewed 5 staff records. 5 of 5 staff records included staff vaccine cards and training information. Facility also keeps a roster of all staff's vaccine and booster status. The facility Health and Wellness Director conducts quarterly training, staff topics included were: hand washing, cough etiquette, PPE(donning and doffing) and infection control. CPR and First aid training for staff were current.

Exit interview conducted with Rosemarie Ferrer and Robin Stouder, whose signature on this document confirms receipt.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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