486803809-4-29-2024-21-AS-KMOA-D5QT78-20240529142820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803809
Report Date: 04/29/2024
Date Signed: 04/29/2024 10:56:40 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240425204905

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:	04/29/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Robin Stouder, Administrator		TIME COMPLETED:	10:42 AM

ALLEGATION(S):

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Staff did not abide to admission agreement

INVESTIGATION FINDINGS:

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During investigation, Licensing Program Analysts (LPAs) Mutialu and Nakagawa determined that the involved resident (R1) lived in an area of the facility that is deemed Independent and not licensed. Due to this, the complaint allegations that facility staff had not abided to admission agreement is unfounded as CCL does not have jurisdiction over the independent living portion of this facility.

No deficiencies cited during inspection.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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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