502701180-5-31-2022-27-AS-CYAG-CEXSNF-20220531140127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701180
Report Date: 05/27/2022
Date Signed: 05/31/2022 02:01:32 PM

Document Has Been Signed on 05/31/2022 02:01 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	COGIR OF TURLOCK		FACILITY NUMBER:	502701180
ADMINISTRATOR:	MONTELLANO, ANTHONY		FACILITY TYPE:	740
ADDRESS:	3791 CROWELL ROAD		TELEPHONE:	(209) 664-9500
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY:	100	CENSUS:	DATE:	05/27/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Janet Johns		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Prelicensing visit made out to this facility on 05/27/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua who were met by the Executive Director Janet Johns. A brief interview was conducted with the Executive Director Johns. Current census was 70 residents. Tour of the facility was conducted. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. It was learned that due to COVID restrictions and guidelines, certain areas were altered to follow the facility mitigation plan for social distancing and follow CDC guidelines. A review of the facility public restrooms was conducted. Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Fire extinguishers, placed throughout this facility, were observed to have been annually inspected on 05/05/2022 by the local fire extinguisher company, Jorgensen Company, and in compliance at this time. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPAs reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. It was observed that there was an oven/stove present and that residents were assisted with skills for baking on site at this time. The use of microwaves and a toaster oven were also present to heat and warm up the food of the residents if necessary. Storage area for chemicals and cleaning supplies was observed to be locked and made inaccessible to the residents at this time. A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COGIR OF TURLOCK	FACILITY NUMBER: 502701180
	VISIT DATE: 05/27/2022

NARRATIVE

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and able to meet the needs of the residents at this time.
A review of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Medication cart was reviewed and the policies for dispensing, storing, and documentation was discussed with facility staff responsible for the medication management at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Memory Care unit for this facility was toured. Delayed egress and other safety measures were observed to be functional at this time.
Exterior grounds of this facility was toured.
Perimeter fence and gates were observed to be functional and in good repair at this time.
Entrances and exits used were observed to be supplied with hand sanitizer and masks at this time.
This facility has been observed to be in compliance at this time.

There were no deficiencies observed during the course of this Prelicensing visit.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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