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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:02:15 AM


Document Has Been Signed on 06/10/2022 11:02 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 ON NAPA ROADFACILITY NUMBER:
496804032
ADMINISTRATOR:CORNEJO, WENDYFACILITY TYPE:
740
ADDRESS:91 NAPA ROADTELEPHONE:
(707) 939-1500
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:105CENSUS: 75DATE:
06/10/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Business Office Manager, Kim FowlkesTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Post-Licensing Inspection. Administrator was unavailable but was notified over the phone of the inspection. LPA met with Business Office Manager, Kim Fowlkes. Building and grounds were found to be clean and in good repair. There are currently 75 residents in care, 22 in memory care and 53 in assisted living.

Facility is conducting COVID screening at the front entrance for visitors. LPA was screened and asked to provide proof of vaccination. All staff have been vaccinated and boosted. An outside party provided vaccination services for the facility two weeks ago making second booster shots available to those who are eligible. Facility does not currently conducting surveillance testing. Staff were observed wearing masks. LPA and administrator discussed infection control plan. Administrator indicated no policy changes regarding visitation and infection control. Facility to submit plan later this month. Personal Protective Equipment is available to support a resident in isolation. LPA observed residents engaged in group activities near the front entrance. Social distancing was maintained.

Medications are centrally stored and locked making them inaccessible to residents. Toxins are secured and inaccessible to residents. Fire extinguishers were last inspected 12/20/2021. LPA observed fire alarm/sprinkler system throughout the facility.

No deficiencies observed during today's inspection.

Exit interview conducted with Business Office Manager. LPA was unable to print, report was emailed to administrator directly during the visit before leaving the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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