Cogir of Vacaville

Allegation investigated: Staff did not prevent facility from being in disrepair

Licensing Program Analyst (LPA) Contreras arrived unannouced to initiate a Complaint Investigation regarding the above allegation and met with Administrator (Admin) Deborah Savoie. LPA requested documents, made observations, and conducted interview. Reporting Party (RP) alleges that facility staff did not prevent facility from being in dispair. Information provided indicated that facility elevator is not funtioning. LPA did a walk through of facility and observed it to be clean and in good repair. There to be a total of three elevators. One out of the three elevators is out of service. Two out of three elevators are fully functional and all residents have access to both elevators. LPA reviewed correspondance provided between Admin, Maintanence Director and Account Manager which show that facility has requested elevator repair parts since 8/05/2026. Maintanence Director received update on 8/14/2026 of pending repair material and approval for work order from Account Manager. On 8/19/2026 Maintanence Director did another follow up with the reponse that repair parts are still awaiting. Contuned onto 9099-C...... Unsubstantiated continued from 9099... There are no incidents that have occurred with residents from the out of service elevator. Facility has taken the needed steps and protocol to ensure that elevator gets replaced and are currently still awaiting repair parts. Facility has also ensured that the other two elevators are functioning and accessible to residents. Admin to send update to CCL once the third elevator is fully functional and operational again. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No Deficiencies Cited during Visit. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 21-AS-20260820130858

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a case management visit and was greeted by Health and Wellness Director Rosemarie Ferrer. The purpose of the visit was to follow up on requested death certificates for three residents (R1,R2,R3) that were not on hospice as stated in the death reports received by CCL. Director called to request death certificates and will be sending them to CCL once received. Family/POA still awaiting certificates for R2 and R3. Admin awaiting phone call regarding R1 death certificate from POA. LPA had conversation with director regarding death certificates when residents are not on hospice. No deficiencies cited during today's visit. Copy of report given and read with administrator.the state’s words, verbatim · CDSS document, Apr 29, 2026

Type of visit: Required - 1 Year

At approximately 10:00am Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit and was greeted by Program Administrator (admin) Deborah Savoie. Facility is a Residential Care Facility for the Elderly (RCFE) offering both independent living (IL) and assisted living (AL) services. Facility has a hospice waiver for five (5) and fire clearance approved for forty nine(49) non-ambulatory residents. There are currently thirty five (35) AL residents in care. LPA and admin toured the buildings and grounds. Facility found to be clean and at a comfortable temperature. All passageways and emergency exits were free from obstruction. Six (6) residents' apartments were inspected and water temperatures in Residents' bathrooms and communal bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Residents' bedrooms were inspected and observed to be clean with all the appropriate furnishings. Seating areas were observed in multiple outdoor spaces throughout the facility for resident use. Storage rooms containing cleaning supplies and other items that could pose a risk were locked. Facility's fire extinguishers were observed charged and were last serviced 11/2025. Facility's fire system is hardwired though fire department. Disaster drills are conducted monthly per shift. LPA toured the facility kitchen and observed all freezers to be clean and food with proper storage including expiration dates noted. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency food supply. LPA observed salon, movie theater, library and activity rooms to be accessible for resident use. Continued to 809C... continued from 809... LPA conducted medication spot check and observed all medications were centrally stored and locked. Centrally Stored Medication Log was up to date. LPA conducted file review for seven(7) residents. All documentation found to be in file. LPA conducted file review for six (6) staff. All documentation found to be in file. Facility does not handle residents P&I monies. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 Personnel Report (Retrieved during visit) LIC308 Designation of Responsibility Liability Insurance No Deficiencies cited during today's visit. Copy of report given and read with administrator.the state’s words, verbatim · CDSS document, Dec 16, 2025

Allegation investigated: Facility is in disrepair

On 05/27/2025, at approximately 10:00 AM, Licensing Program Analysts (LPAs) Julie Florio and Ethel Contreras arrived unannounced to initiate a 10-day complaint investigation regarding LIC802 - Complaint Report #21-AS-20250520120117, which was received by Community Care Licensing (CCL) on 05/20/2025. LPAs met with Deborah Savoie, Executive Director (ED). During inspection, LPAs obtained documents, made observations, and conducted interviews. Today, based on observations made and pictures obtained, the facility's siding is in disrepair. However, LPAs obtained conflicitng information when observing a sampling of resident units where windows and doors were clear of any evidence of mold, mildew, or moisture. Additonally, based on interviews conducted with Staff 1 (S1) and ED, the facility owners and management complany have been replacing the defective siding in stages and have replaced about twenty percent (20%) of it over the past 4 years. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Further, both S1 and ED state that the current plans are to replace the entire exterior siding, gutters, windows, and balconies which is an estimated twenty million dollar ($20,000,000) project. The project is currently is in the permit, design, funding stages. Based on record review, interviews conducted, and observations made, the allegation that the facility is in disrepair is UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Deborah Savoie, Administrator, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 27, 2025 · control 21-AS-20250520120117

Type of visit: Case Management - Annual Continuation

At approximately 2:20 PM, Licensing Program Analysts (LPAs) Julie Florio and Elias Magdaleno arrived unannounced to conduct a case management -- annual continuation inspection and met with Rosemarie Ferrer, Health & Wellness Director. At approximately 2:40 PM, LPAs conducted file review of ten (10) resident files and ten (10) staff files and observed the following: ten (10) of ten (10) resident files reviewed contained all the required documents per Title 22 regulations. Ten (10) of ten (10) staff files reviewed have all of the required paperwork including proof of first aid training. However, files for Staff 1 (S1) and Staff 2 (S2) were observed missing proof of required training hours and all staff files reviewed were observed missing proof on initial training hours, (see LIC809Ds). At approximately 4:30 PM, LPAs reviewed medications and medication records which are maintained and stored in compliance with regulation. Facility and residents' families work together to coordinate medical and dental appointments and transportation to and from visits. Facility does not manage cash resources for residents. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12 month period, may result in a civil penalty assessment. Exit interview conducted with Health & Wellness Director, whose signature on form confirms receipt. Appeal rights provided.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Feb 25, 2025

The state marks this report as 13 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not abide to admission agreement

During investigation, Licensing Program Analysts (LPAs) Mutialu and Nakagawa determined that the involved resident (R1) lived in an area of the facility that is deemed Independent and not licensed. Due to this, the complaint allegations that facility staff had not abided to admission agreement is unfounded as CCL does not have jurisdiction over the independent living portion of this facility. Nothe state’s words, verbatim · CDSS document, Apr 29, 2024 · control 21-AS-20240425204905

Allegation investigated: Personal rights: Sexual abuse

At approximately 1:40 PM, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to deliver the results from an investigation on the above allegation. LPA met with Administrator Robin Stouder. The investigation included interviews with staff, family members and a review of records which showed resident was not sexually assaulted. Staff documentation and interviews conducted with family showed that resident has expressed on multiple occasions, for several years, the same symptoms. Continued on 9099-C Unfounded Continued from 9099... On 01/ 27/24 at approximately 5:30 PM, resident pressed pendant and presented that they were in severe pain and wanted to go to hospital. Resident was taken to the hospital to address their concerns. While in the Emergency Room resident stated that a staff member had sexually abused them. Resident was seen by physician, whose diagnosis was acute urinary retention and rectal pain. Exam did not report any sexual penetration. Resident received a prescription and instructed to schedule an appointment with their primary care physician and was discharged at 11:22 PM, 1/27/24. Resident returned to facility. Interviews with Family Member 1 (FM1) and Family Member 2 (FM2) state that the resident does not remember making the allegation of sexual abuse while in the Emergency Room, and was only seeking treatment for their pain and discomfort, and recanted the allegation to both FM1 and FM2. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unfounded.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 21-AS-20240129151241

Type of visit: Required - 1 Year

On 01/26/2024 at 10:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Health and Wellness Director Rosemarie Ferrer and administrator Robin Stouder (cert #6047960740 exp. 4-23-24) and explained the purpose of the visit. Administrator certificate is current. LPA Benson and Rosemarie Ferrer toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, four (4) bathrooms, common areas, kitchen, storage areas and yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet. The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the residents. All required postings are displayed within facility. No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 01/17/24, the facility has been conducting drills every month. The facility is in compliance. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator.the state’s words, verbatim · CDSS document, Jan 26, 2024