216804000-2-5-2024-21-AS-CFES-CZY27K-20240129160851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 01/29/2024
Date Signed: 02/05/2024 02:02:52 PM

Document Has Been Signed on 02/05/2024 02:02 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: 49	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director/Administrator, Susan Edwards		TIME COMPLETED:	04:15 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 11:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year 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. Upon arrival, LPA was informed that there were 49 residents in care and 9 direct care staff on-site. At approximately 11:30AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 12:00PM, LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected April 2023. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected December 2023. Facility's last fire/disaster drill was conducted January 2024. LPA reviewed staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. 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: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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: 01/29/2024

NARRATIVE

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**Report has been Amended**
Continued from LIC809

As part of their Non-Compliance Plan, LPA also requested and reviewed documents for all employees hired from November 2023 to January 2024. Review of documents showed that facility hired one individual during this time frame.
Document review showed that facility has 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 also followed up on an incident report/SOC-341 that was submitted to Community Care Licensing (CCL).

Incident Report 1/SOC341: CCL received an incident report/SOC-341 report on 01/08/2024 and 01/10/2024. Reports stated that on 01/07/2024, during a routine check, facility staff found Resident 1 (R1) and Resident 2 (R2) in bed together in R1's room. Facility self-reported incident, facility contacted responsible parties for both residents. Facility has implemented the following;
· 1:1 supervision for R2,
· 30 minute checks after 8PM
· Continuous alert charting for R1 and R2
· Service care plans have been updated for both residents

Facility understands that residents are able and allowed to have a relationship with each other. Facility understands that if residents were prevented having a relationship or are prohibited from seeing each other, it may be a personal rights violation. Based on review of incident report and SOC-341, Facility has been compliant with Title 22 Regulations regarding Personal Rights.

Incident Report 2: Executive Director also informed LPA that yesterday evening, 01/28/2024, facility staff found a box of wine in Resident 3's (R3) room. The wine was immediately removed from R3's room. LPA informed that R3 has a Physician's Order to have alcohol, and an LIC624/Unusual Incident Report submitted to the Regional Office.

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: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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: 01/29/2024

NARRATIVE

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**Report has been Amended**
Continued from LIC809C

Facility sent out a notice to all Responsible Parties outlining items that are not allowed to be in the building and plans on conducting an in-service training for staff reviewing prohibited items such as alcohol. (This regulation has been cited, see LIC809D, Regulation 87705(f)(2)).”

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.

**An Immediate Civil Penalty in the total amount of $250 is being assessed for a repeat violation of Regulation 87705(f)(2) more than once in a 12 month period. (See LIC421IM)**

Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC809D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.
Physical Copy of signatures on file.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/05/2024 02:02 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

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:
	Deficient Practice Statement
1 2 3 4	Based on documents reviewed, Licensee did not comply with the section cited above. A bottle of wine was observed to be in R1’s room. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee to submit self certification that training for Regulation 87705(f)(2) will be conducted for all staff by POC due date of 01/30/2024. 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: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 02/08/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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