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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:51:36 PM


Document Has Been Signed on 01/27/2023 03:51 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: 73DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Wendy CornejoTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/27/2023 to conduct a required - 1 year inspection. The inspection was focused on the infection control practices and procedures of this facility. LPA signed in and screened for COVID upon arrival. LPA met with administrator, Wendy Cornejo.

Facility is a two story residential care facility for the elderly with assisted living and a memory care unit. LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. Fire extinguishers inspected were charged and current. Carbon monoxide and smoke detectors were present and operational throughout the facility. Toxins were locked and secured in housekeeping closets. Medications were locked and secured. Bathrooms had necessary grab bars and nonskid flooring. Facility has sufficient perishable and nonperishable food. High touch surface areas are disinfected daily. Facility has sufficient personal protective equipment to support a resident in isolation. LPA and administrator discussed resident and staff record keeping. Memory care unit has fall detection devices installed. Device is called SafelyYou and only records when resident falls for a time interval of approximately 10 minutes. LPA will follow up with facility for documentation.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 day's of today's inspection:

LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
Evidence of Liability Insurance

Exit interview conducted with administrator Wendy Corenjo and a copy of this report sent to her email.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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