216804000-10-27-2023-21-AS-CFES-CWZUD2-20231027152849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:28:55 PM

Document Has Been Signed on 10/27/2023 03:28 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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: 53	DATE:	10/27/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Administrator/Executive Director, Susan Edwards		TIME COMPLETED:	03:35 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	At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Administrator/Executive Director, Susan Edwards. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. The purpose of today's visit is to conduct a Non-Compliance (NCC) inspection and to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA requested and reviewed documents for all employees hired from July 2023 to October 2023. Review of documents showed that facility hired 5 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives. LPA was informed that an all staff in-service training is scheduled on 10/31/2023 to review the following topics: Elder Abuse and Mandated Reporting. LPA obtained copies of training documents. LPA was informed that facility has scheduled two renovations to be done. The facility's bathroom located in their smaller neighborhood will be turned into a laundry room, and their roof tiles will be replaced. Facility has ensured that all construction tools required for renovations will be inaccessible to residents. Executive Director stated that there is a locked room available for contractors to leave their equipment in during renovations. LPA was informed that only the Executive Director, Maintenance Director, and Contractor will have keys to access the room. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 10/27/2023

NARRATIVE

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Continued from LIC809

LPA followed up on the following self-reported incidents:

Incident Report/SOC341 #1: CCL received an incident report/SOC-341 report on 06/30/2023. Reports state that on 06/29/2023, Resident 1 (R1) was visiting the facility's smaller neighborhood with their robotic therapy cat. Facility staff observed Resident 2 (R2) approach R1 to pet the cat. R1 became upset and hit R2 across the face. R2 then hit R1 back and they started pulling each other's hair. Facility staff immediately separated the two residents. Facility made all appropriate notifications per regulation.

Incident Report/SOC341 #2: CCL received an incident report/SOC-341 report on 07/03/2023. Reports state that on 07/02/2023, R1 and Resident 3 (R3) had a physical altercation that was stopped by Resident 4 (R4). Facility does not know how altercation started but were able to separate R1 and R3 to be evaluated. Facility observed R1 to have an injury and contacted Emergency Personnel. Personnel determined that R1 did not need medical attention. Facility made all appropriate notifications per regulation.

SOC341 #3: CCL received an SOC-341 report on 07/20/2023. Report states that on 07/19/2023, Resident 5's (R5's) Hospice Team reported to the facility the following information: the Chaplain observed R5's Responsible Party slap their arm during lunchtime. R5 was seen to have placed feces on the dining table. Executive Director spoke with Responsible Party and was told that they were trying to prevent more feces from being placed on the table during the meal. Facility made all appropriate notifications per regulation.

Incident Report/SOC341 #4: CCL received an incident report/SOC-341 report on 09/06/2023. Reports state that on 09/04/2023, Staff Member 1 (S1) reported a concern to the Executive Director regarding an incident they observed with Staff Member 2 (S2) and R4. S1 reported feeling uncomfortable with the way S2 addressed R4 when helping with their care needs. Executive Director conducted an internal investigation and concluded that S2 needed more training on how to appropriately communicate with residents while providing care. Facility conducted supplemental training with S2. Facility made all appropriate notifications per regulation.

LPA conducted interviews during visit and was informed that S2's communication with residents has improved. LPA obtained copies of training documents.

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 10/27/2023

NARRATIVE

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Continued from LIC809C

Incident Report/SOC341 #5: CCL received an SOC-341 report on 09/20/2023. Report states that on 09/19/2023, Resident 6 (R6) approached facility staff in the medication room for assistance with dental hygiene. Resident 7 (R7) was observed telling R6 not to go into the medication room and tightly grabbed R6 by the arm. Staff intervened and attempted to place themselves between R6 and R7. R7 was observed to escalate and increase their aggressive behaviors towards staff by yelling and not letting go of R6. Once staff were able to separate R6 and R7, staff observed R7 repeatedly knock on the medication room's door in an aggressive manner while they assisted R6. Facility made all appropriate notifications per regulation.

Per conversation with Executive Director, LPA was informed of the following:

R1 has been continuously monitored by staff for increased behavior. R1 was re-evaluated by their Physician and had a medication change. R1 has been observed to have less aggression.
R7 has been evaluated by their Physician and had a medication change. Aggression towards staff has continued to occur when they assist R6. Facility has communicated with R7's Responsible Party regarding these incidents. Due to their care needs, R7's Responsbile Party has decided to relocate them to another facility.

Facility to submit in-service training scheduled for 10/31/2023 to CCL once completed. Documents to be submitted by Monday, 11/06/2023.

No Deficiencies Cited during visit.

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: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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