216804000-5-2-2024-21-AS-VBEI-D5CPLX-20240517112528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:25:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
03/08/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240308152416

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: 47	DATE:	05/02/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Susan Edwards, Administrator/Executive Director		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff did not provide responsible party with 30 day eviction notice.

INVESTIGATION FINDINGS:

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At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Susan Edwards.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “Staff did not provide responsible party with 30 day eviction notice.”
Complainant alleged that Resident 1 (R1) and their designated representatives conducted a meeting with the facility where it was discussed that R1 be relocated or discharged from the facility. Complainant stated that the facility did not provide R1 and their designated representatives with any documentation and did not use the word “eviction” and only used terms like “decision to relocate” or “discharge.” Complainant stated that facility did not provide R1 and their designated representatives with a written eviction notice.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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 4

Control Number 21-AS-20240308152416

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/02/2024

NARRATIVE

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Continued from LIC9099

LPA conducted staff interviews and found that R1 is still a resident at the facility and has not been evicted. Review of R1’s file showed a document that addressed R1’s behaviors and interventions and stated that failure to uphold the commitments agreed upon may result in alternative placement being needed. Per Administrator, R1's Responsible Party received and acknowledged the document but refused to sign. A formal letter of this document was also received by the Department on 03/20/2024. Based on review of documents, interviews conducted, and observations made, 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.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
03/08/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240308152416

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:	DATE:	05/02/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Susan Edwards, Administrator/Executive Director		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff did not report incident to CCL

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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 4

Control Number 21-AS-20240308152416

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/02/2024

NARRATIVE

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Continued from LIC9099A

Based on documents reviewed and observations made, this Agency has investigated the above allegation. We have found that the allegation is Unfounded. A finding that the complaint is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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