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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:00:54 PM


Document Has Been Signed on 06/20/2023 03:00 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: DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator, Wendy CornejoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cogir on Napa Road for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by Administrator, Wendy Cornejo and was granted access into the facility.

During the Case Management-Incident Inspection, LPA discussed an incident report that was forwarded to the Regional Office on June 13, 2023. LPA learned that there was an incident that a resident was throwing up discolored blood. Primary Care Physician and Responsible Party were notified of the incident. Proper Reporting Requirements were met. Resident transitioned back from the Medical Facility. Administrator disclosed that the Care Plan/Appraisal Plan was just updated with all appropriate parties (Responsible Party and Primary Care Physician). Furthermore, the residents responsible party will be looking into other additional care regarding Resident #1.

No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator due to printer issues.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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