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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803810
Report Date: 02/18/2022
Date Signed: 02/23/2022 11:12:06 AM


Document Has Been Signed on 02/23/2022 11:12 AM - 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 NORTH BAYFACILITY NUMBER:
486803810
ADMINISTRATOR:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:2261 TUOLUMNE STTELEPHONE:
(707) 552-3336
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:83CENSUS: 54DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Claudia Morales, Executive Director/AdministratorTIME COMPLETED:
12:47 PM
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Licensing Program Analyst (LPA) Araceli Canela, arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Executive Director/Administrator, Claudia Morales. The annual inspection is focused on the Infection Control procedures and practices of this facility.

This facility is licensed to care for up to 83 residents, of which 55 residents can be non-ambulatory, 28 ambulatory and there is an approved hospice waiver for three (3) of the residents to be on Hospice services. At this time the facility has 54 residents living in the facility. LPA toured facility and grounds with Executive Director and Maintenance Director, Andrew Glaes and observed COVID-19 precaution signs posted in common areas and bathrooms to promote face coverings, Coughing etiquette and hand washing. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility, yet LPA came in to the facility at the same time as two other individuals were coming in and facility front desk staff failed to request LPA to sign in, take temperature or follow Covid Guidance entrance procedure. . Infection control practices were present in the following: face coverings, daily monitoring, temperatures checks for residents and staff, daily facility cleaning of high touch areas and 30-day PPE supply. Facility will follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily and every night. Bathrooms are equipped with liquid soap, hand sanitizer and paper towels, Covid hand washing posters and garbage can. Covid-19 Mitigation plan was submitted to the department on 6/25/2021. Caregivers have completed PPE training but Executive Director will inform LPA on N-95 Fit testing for staff. LPA observed hand sanitizers throughout facility.
In addition, facility was found to be Clean at a comfortable temperature with all exits free from obstruction, and emergency evacuation chairs were observed on the top stairs. Fire Extinguishers were found to be charged and serviced 11/18/2021. Facility has hard wired smoke alarms and fire sprinklers that are serviced yearly. At time of inspection, there was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations and staff were observed wearing face covering.
No citations issued during todays visit, this report emailed to facility due to printer issues.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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