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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 03/15/2022
Date Signed: 03/15/2022 01:10:34 PM


Document Has Been Signed on 03/15/2022 01:10 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 ON NAPA ROADFACILITY NUMBER:
496804032
ADMINISTRATOR:CORNEJO, WENDYFACILITY TYPE:
740
ADDRESS:91 NAPA ROADTELEPHONE:
(707) 939-1500
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:105CENSUS: 72DATE:
03/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Wendy CornejoTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced at approximately 9:15 AM on 3/15/2022 to conduct a Pre-licensing inspection. LPA was greeted by staff and asked to screen for COVID symptoms. LPA met with administrator, Wendy Cornejo.

Facility is a two story building with assisted living and a memory care unit. There are currently 22 residents in memory care and 50 residents in assisted living. There are 2 residents on hospice in memory care. Facility has a fire clearance that permits 90 non-ambulatory residents and 15 bedridden residents. Bedridden residents to be housed on the first floor.

LPA toured facility with administrator. Rooms contained appropriate furnishings. Bathroom showers had the necessary grab bars and nonskid flooring. Water temperature tested at one sink accessible to clients was measured at 110.4 degrees F which is within regulation. Carbon monoxide detectors were observed as well as smoke alarms and a sprinkler system. At least 3 fire extinguishers were observed which were last inspected on 12/20/21. Facility has an emergency generator. Toxins were observed to be inaccessible and kept in locked housekeeping closets. Medications were also determined to be kept secured and inaccessible to residents in care. The memory care unit has a locked medication room. Assisted living has locked medication carts and central medication storage in a room by the front office. Sufficient perishable and non-perishable food was observed in the kitchen.

LPA conducted record review. LPA reviewed 10 resident files which included Physician's Reports, Preplacement appraisals, and admission agreements. There are two separate files for residents, a medical file and an administrative file. Admission agreements found in the administrative file. LPA reviewed 10 staff files. 10 out of 10 staff files had mandated reporter documentation and criminal background clearance documentation. 10 out of 10 staff files had first aid training, and 5 out of those 10 had CPR as well.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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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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 ON NAPA ROAD
FACILITY NUMBER: 496804032
VISIT DATE: 03/15/2022
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LPA observed licensing posters, complaint posters, an activity schedule, and ombudsman poster. There is an operating resident council.

Component III waived due to administrator operating a current licensed facility.

LPA requested proof of liability insurance during inspection.

LPA will notify Application Unit so application process may proceed.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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