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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:41:17 PM


Document Has Been Signed on 02/20/2024 03:41 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
SANTA ROSA RO, 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: 65DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Wendy Cornejo, AdminTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Wendy Cornejo, Administrator. Facility currently has nine [9] residents on hospice which is allowable per the facility's Hospice Waiver. Facility contact information was reviewed.

At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA and Admin observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Cleaning supplies not stored with food items. Water temperature in sink(s) accessible to residents in care measured at 106 degrees F which is within the allowable range of 105 to 120 degrees F.



Fire extinguishers were last inspected 11/21/2023. Smoke/Carbon Monoxide detectors and sprinklers located throughout the facility were tested and operational, last inspected 2/5/2024. Elevator permits expired 11/29/2023; however, annual inspection by State of CA, Dept of Industrial Relations is scheduled, LPA verified via email correspondence. Stairwells has evacuation chairs present. Facility’s last quarterly disaster drill was conducted on 2/7/2024. Facility has a backup generator for use during a power outage.

At approximately 11:00am LPA conducted a review of five [5] resident records. All required documents present. Four [4] of out of the five [5] residents reviewed are on hospice; respective hospice care plans present. At approximately 2:00pm LPA conducted review five [5] staff files. All required documents present, required training completed.

At approximately 12:30pm LPA conducted a spot check of medication and medication records. Medication is centrally stored in Medication carts which are stored in locked Medication room, refrigerator present for refrigerated medications.


Report continued on LIC 809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COGIR ON NAPA ROAD
FACILITY NUMBER: 496804032
VISIT DATE: 02/20/2024
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Continued from 809...

Wendy Cornejo Administrator Certificate 6018066740 expires 7/22/24. All fees are current as of this time.

LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster Plan. No updates needed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Evidence of Liability Insurance

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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