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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803809
Report Date: 02/25/2025
Date Signed: 02/25/2025 05:01:30 PM

Document Has Been Signed on 02/25/2025 05:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:COGIR OF VACAVILLEFACILITY NUMBER:
486803809
ADMINISTRATOR/
DIRECTOR:		STOUDER, ROBINFACILITY TYPE:
740
ADDRESS:799 YELLOWSTONE DRIVETELEPHONE:
(707) 447-7496
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 49CENSUS: 31DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Deborah Savoie, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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At approximately 2:00 PM, Licensing Program Analysts (LPAs) Julie Florio and Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and were greeted by Deborah Savoie, Administrator, who started at the facility about three weeks ago. Facility understands they shall request a change of administrator with CCL within 30 days of such change. Facility is a Residential Care Facility for the Elderly (RCFE) offering both independent living (IL) and assisted living (AL) services. Currently, facility has thirty-one (31) AL residents in care. Facility has a Hospice waiver for five (5) and is approved for 49 non-ambulatory residents.

At approximately 2:30 PM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a two story facility, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed pull cords and grab bars present in AL rooms.

Carts containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. LPAs also observed lanterns and flashlights for emergency preparedness. Medications were centrally stored and locked. There is a shaded seating area in the courtyard with outdoor space for activities. LPAs observed an activity schedule, a library, and an activity room equipped with a poker table, karaoke machine, bingo, puzzles, art supplies, a large television, and more. Facility has a barbershop/beauty salon where residents are able to get haircuts, manicures, and other beauty services.

Facility has internet service and both laptops and iPads available to residents in care. The facility's telephone was tested and operational during inspection.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 13
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 OF VACAVILLE
FACILITY NUMBER: 486803809
VISIT DATE: 02/25/2025
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Continued from LIC809C...

Fire extinguishers were last inspected 10/24. Facility is hardwired with smoke and carbon monoxide detectors, as well as sprinklers which are located throughout the facility. The Fire Marshal last inspected the facility 11/2024. Facility conducts monthly disaster drills with the last drill completed 1/2025. LPAs reviewed the facility's infection control plan and the emergency disaster plan, which was last updated 2/2025. LPAs observed the first aid kit and a supply of PPE.

LPAs will return at a later date to complete the annual inspection. LPAs will review resident files, staff files, and medications and medication logs during that visit.

Required Change of Administrator Documents:

  • LIC 308 (Designation of Facility Responsibility)
  • Active and Current Administrator Certificate
  • First Aid Certificate
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative TB test
  • LIC 9182 (Criminal Record Exemption Transfer Request)
  • LIC 508 (Criminal Record Statement)
  • Copy of Driver's License or Passport that is not expired
  • Statement signed by Licensee requesting Change of Administrator

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC610E - Emergency Disaster Plan (updated)

No deficiencies were cited during inspection.

Exit interview conducted with Administrator whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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