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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803809
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:26:17 PM


Document Has Been Signed on 01/26/2024 02:26 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
SANTA ROSA RO, 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: 34DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Robin StouderTIME COMPLETED:
02:30 PM
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On 01/26/2024 at 10:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Health and Wellness Director Rosemarie Ferrer and administrator Robin Stouder (cert #6047960740 exp. 4-23-24) and explained the purpose of the visit. Administrator certificate is current.

LPA Benson and Rosemarie Ferrer toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, four (4) bathrooms, common areas, kitchen, storage areas and yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.



The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the residents. All required postings are displayed within facility.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 01/17/24, the facility has been conducting drills every month.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: (530) 282-2393
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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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