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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:37:00 PM


Document Has Been Signed on 04/22/2024 12:37 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 SAN RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR:SUSAN EDWARDSFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(415) 472-6530
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: 45DATE:
04/22/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Susan Edwards, Administrator/Executive DirectorTIME COMPLETED:
11:15 AM
NARRATIVE
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At approximately 9:10AM, Licensing Program Analysts (LPAs) Florio and Felias arrived unannounced to conduct a Case Management - Legal/Non-compliance 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.

LPAs requested and reviewed documents for all employees hired from January 2024 to April 2024. Review of documents showed that facility hired 2 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.

LPAs conducted a walkthrough with Executive Director. During walkthrough, LPAs observed that a medication cart was unattended and unlocked. LPAs observed that routine and narcotic medications were on top of the unlocked cart. LPAs notified the medication technician on duty who immediately put the medications away and locked the cart (this deficiency has been cited, see LIC809-D, 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 $1,000 is being assessed for a repeat violation of Regulation 87705(f)(2) for a third or subsequent cited violation within 12 months of the last violation. (See LIC421IM)**

Exit interview conducted. Copy of report, LIC809D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
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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Document Has Been Signed on 04/22/2024 12:37 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
SANTA ROSA RO, 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: 04/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2024
Section Cited
CCR
87705(f)(2)

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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:
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LPAs notified the medication technician on duty who immediately put the medications away and locked the cart.
Licensee to submit self certification that training for Regulation 87705(f)(2) will be conducted for all Medication Technicians by POC due date of 04/24/2024.
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 Licensee did not comply with the section cited above. LPAs observed medication cart was unattended and unlocked. LPAs observed routine and narcotic medications were on top of the unlocked cart. This poses an immediate health and safety risk to residents in care.
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Training to review items that are inaccessible to residents in care and to review proper storage of medications. 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 05/2/2024.

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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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