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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803810
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:42:55 PM


Document Has Been Signed on 11/03/2022 01:42 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 NORTH BAYFACILITY NUMBER:
486803810
ADMINISTRATOR:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:2261 TUOLUMNE STTELEPHONE:
(707) 552-3336
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:83CENSUS: 59DATE:
11/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Tracy Freudendahl, Executive DirectorTIME COMPLETED:
01:50 PM
NARRATIVE
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On 11/3/2022 Licensing Program Analyst (LPA), D. Tobola arrived unannounced for the purpose of conducting a Case Management visit and was greeted by Executive Director, Tracy Freudendahl. LPA conducted interview with Executive Director regarding a resident related incident reported to CCLD. On the evening of 9/18/2022 facility staff had reported a resident (R1) to be missing from their apartment during a routine room check. Resident R1 had AWOL (away without leave) and was later found to have been located outside of the facility. Based on a review of records, LPA found that resident R1 is not able to leave the facility unassisted.

LPA and Executive Director discussed plan in place for AWOL prevention including security monitoring and updated hours for front desk supervision. No other related incidents have occurred since.

A copy of the report was given to the Executive Director.

Appeal Rights Given.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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Document Has Been Signed on 11/03/2022 01:42 PM - It Cannot Be Edited

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 NORTH BAY
FACILITY NUMBER: 486803810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited

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Personnel Requirements-General: Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This was not met as evidence by:**
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Based on reported incident and interview with staff, resident (R1) was found to have AWOL from the faciliy while under facility staff supervision. This serves as an immediate health and safety risk to residents in care.
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as well as evening hours. POC for the deficiency has been cleared during the visit.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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