216804000-7-14-2023-21-AS-KMOA-CU6LW9-20230728090645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:00:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230502105424

FACILITY NAME:	COGIR OF SAN RAFAEL		FACILITY NUMBER:	216804000
ADMINISTRATOR:	SUSAN EDWARDS		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(415) 472-6530
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70	CENSUS: 50	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Executive Director/Administrator, Susan Edwards		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff storing items in resident's refrigerator

INVESTIGATION FINDINGS:

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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived uannnounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Susan Edwards.
During the course of the investigation, LPA reviewed and requested documents, made observations, and conducted interviews. There is an allegation that Staff are storing items in resident’s refrigerator. Report states that in September 2022, an opened and frozen alcoholic beverage was found in Resident 1’s (R1's) freezer. Pictures provided to LPA confirmed that an alcoholic beverage was presented to staff. Interviews conducted confirmed that an alcoholic beverage was found on the facility premises where it was accessible to Residents in Care and that Staff and Facility Management were notified. Interviews conducted indicated that residents are only allowed to have alcohol if they have a Physician’s Order. If a Resident can have alcohol, it is stored inaccessible to residents in the Facility’s kitchen. Reporting Party stated that no known visitor or family member of R1 placed the alcoholic beverage in their room. This allegation is Substantiated.
Continued on LIC9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230502105424

FACILITY NAME:	COGIR OF SAN RAFAEL		FACILITY NUMBER:	216804000
ADMINISTRATOR:	SUSAN EDWARDS		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(415) 472-6530
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70	CENSUS: 50	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Executive Director/Administrator, Susan Edwards		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident in care
Staff did not observe change in resident's condition
Staff did not respond to resident's call cord

INVESTIGATION FINDINGS:

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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived uannnounced to continued a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Susan Edwards.
During the course of the investigation, LPA reviewed and requested documents, made observations, and conducted interviews. There is an allegation that Staff did not seek timely medical attention for resident in care. The Report states the following concerns: Staff did not take Resident 1 (R1) to the hospital or notify R1’s Responsible Party when R1 complained of pain in their legs and feet in March 2023 and April 2023. Report states that on the night of 3/25/2023, R1 complained of their feet hurting and burning. Documents reviewed showed that Facility notified R1’s Responsible Party on 03/25/2023 of R1’s condition and indicated that R1 was checked on by staff every hour. Documents reviewed stated that R1 was observed to not be in pain or discomfort. Review of R1’s Medication Record also indicated that R1 had a pain medication administered to them on the night of 03/25/2023.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 21-AS-20230502105424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 07/14/2023

NARRATIVE

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Continued from LIC9099A

On 04/29/2023, R1 communicated to Staff that they did not feel well and had leg pain. Review of Facility documentation and incident reports indicated that R1’ s Responsible Party was contacted and informed of R1’s condition on 04/29/2023. Report reviewed stated R1’s Responsible Party declined having 911 called for R1, and that they did not want emergency transport provided. This allegation is Unsubstantiated.

There is an allegation that Staff did not observe change in resident’s condition. The Report states the following concerns: Staff did not observe R1’s wheezing and coughing, Staff did not observe R1’s stomach distention, and Staff did not observe a change in R1’s legs.

Review of R1’s Progress notes showed that on 04/24/2023, Staff observed R1 to have a moist cough. Staff contacted R1’s Primary Care Physician on 04/25/2023 when it was observed that R1’s cough did not go away. On 04/26/2023, R1’s Physician ordered a test to be conducted and R1 was prescribed antibiotics. Documents reviewed indicated that Facility communicated with R1’s Responsible Party on 04/28/2023 when R1’s antibiotics arrived and when they received their first dose.

Reporting Party stated that it was observed R1 had distension in their stomach on 04/29/2023. Review of R1’s Hospital Notes,dated 04/29/2023, stated that distension was observed. Notes continued to state that R1 denied having any abdominal pain when asked and that R1 had a bowel movement on 04/28/2023, and passed gas that morning prior to their hospital visit. Review of R1’s Bowel Movement Chart indicated that R1 had a bowel movement the morning of 04/27/2023 and again on 04/29/2023.

Reporting Party stated that Staff did not observe a change in R1’s legs. Based on interviews conducted, LPA received inconsistent information regarding the condition of R1’s legs and feet. Interviews conducted indicated that on the morning of 04/29/2023, Staff Member 1 (S1) observed R1’s legs and feet to be warm, red, and swollen. S1 reported the observation to Staff Member 2 (S2). S2 observed R1’s legs to be warm, red, swollen and that R1 had an elevated temperature when they went to administer a pain medication for them. S2 notified Facility’s Health and Wellness Director of their observations and asked R1 if they would like 911 to be called. R1 refused. Interviews conducted indicated that in the afternoon of 04/29/2023, S1 observed that R1’s legs were worse than they were in the morning while S2 observed that R1’s legs were in the same condition as before. Review of Facility documentation and incident reports indicated that R1’ s Responsible Party was contacted and informed of R1’s condition on 04/29/2023.

Continued on LIC9099C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 21-AS-20230502105424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 07/14/2023

NARRATIVE

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Continued from LIC9099C

Review of Facility’s Clinical and Policy Procedure Manual states that “Facility staff are to notify the Health and Wellness Director or a Medication Technician when there is a resident change in status. A change in resident status can include the following: Elevated or subnormal temperature, wheezing, complaints of pain or discomfort, or change in skin integrity.” In addition, Review of R1’s Care Plan dated,05/22/2022, did not indicate a care need for R1 to have regular skin checks by the facility. This allegation is Unsubstantiated.

There is an allegation that Staff did not respond to Resident’s Call cord. Report states that R1 pulled their call cord and no one came to assist them. Review of R1’s call light records for the months of March 2023 and April 2023 indicated that all calls were responded to within a time frame of 10 minutes or less. Staff interviews conducted stated that there haven’t been any concerns regarding the facility’s call light system and that it has been functioning appropriately. This allegation is Unsubstantiated.

A finding that the Complaint Allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 21-AS-20230502105424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 07/14/2023

NARRATIVE

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Continued from LIC9099

A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 21-AS-20230502105424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/15/2023 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia:(2)Over-the-counter medication... alcohol... and toxic substances...This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not	1 2 3 4 5 6 7	Licensee to submit self certification that training on Regulation 87705(f)(2) will be conducted for all staff by POC due date of 07/15/2023. Training to review items that are inaccessible to residents in care. Licensee to conduct Inservice Training and submit a sign in sheet to CCL that includes the following:
	8 9 10 11 12 13 14	comply with the section cited above. An opened alcoholic beverage was observed to be in R1’s room. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Date,Training Topic, Name/Job Role, and Signatures by POC due date of 07/25/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

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