486803810-2-9-2023-21-AS-DTOA-CNVUZS-20230209150200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803810
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:02:07 PM

Document Has Been Signed on 02/09/2023 03:02 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 NORTH BAY		FACILITY NUMBER:	486803810
ADMINISTRATOR:	DOMIZIO, ANNEMARIE		FACILITY TYPE:	740
ADDRESS:	2261 TUOLUMNE ST		TELEPHONE:	(707) 552-3336
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	83	CENSUS: 38	DATE:	02/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Dina Lopez, Health Services Director		TIME COMPLETED:	02:15 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	On 2/9/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Health Services Director, Dina Lopez. Director, Tracy Freudendahl was also present and informed of the inspection. The facility currently provides care for 38 residents, 2 of which are receiving hospice services and none of which with a of diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with lead staff. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/13/2022 at the time of the visit. Smoke detectors were tested and found to be in working order. In addition, the Director will be providing a copy of the update Fire Inspection to CCLD for review. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be ending lunch and proceeding to independent activities both in their respective apartments, in activity rooms an common spaces throughout the facility. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens. There was a supply of hygiene products and paper products available for resident use along with resident's personal toiletry items. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid training on file. Toxins are stored in locked maintenance closets and carts located throughout the facility. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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 NORTH BAY	FACILITY NUMBER: 486803810
	VISIT DATE: 02/09/2023

NARRATIVE

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LPA Tobola measured water at faucets accessible to residents and measured between 106.7 and 119.6 degrees F which is within Title 22 Regulations between 105 and 120 degrees F. During the inspection, LPA Tobola found elevators to be operating, however observed 2 out of 2 elevators in need of inspection renewal date of 2/4/2023. Director to contact appropriate Department for renewal and provide updated proof of cleared elevator inspection to CCLD.

Infection Control:
Facility has submitted an infection control plan for review. Posters have been placed at the front door and throughout the facility, and facility has a station near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. There is a sufficient amount of PPE supplies available. All staff and visitors were observed to have appropriate face coverings and following facility COVID protocols. Residents and staff are also screened for symptoms on a daily basis.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

LPA requested the following documents be sent to CCL by COB 2/23/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/09/2023 03:02 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: 02/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, the licensee did not comply with the section cited above in 2 out of 2 elevators in need of inspection renewal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Director agrees to contact appropriate Department and request for updated elevator inspection. Proof of inspection certificate for 2 out of 2 elevators to be submitted to CCLD by POC due date 2/16/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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