216804000-8-8-2024-21-AS-VBEI-D84VM7-20240813163300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:48:28 PM

Substantiated

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
04/24/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240424094747

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: 44	DATE:	08/08/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Regional Executive Director, Davina Barker, and Health and Wellness Director, Victoria Mozaffari		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not provide representative with an updated care plan with explanation of care charges
Facility does not respond to representative timely

INVESTIGATION FINDINGS:

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At approximately 12:50PM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to deliver findings for this Complaint Investigation regarding the above allegations and met with Regional Executive Director, Davina Barker, and Health and Wellness Director, Victoria Mozaffari.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “Facility did not provide representative with an updated care plan with explanation of care charges.” Complainant stated that R1’s Responsible Party was being charged $100 per day for R1 to receive wound care treatment and that R1’s care increased from a Level 5 to a Level 9 with no explanation. Interview conducted with Facility’s Health and Wellness Director (HWD) stated that R1 was put on a Temporary Service Plan (TSP) in February 2024 due to increased care needs.
Continued on LIC9099C

Substantiated

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: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240424094747

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: 08/08/2024

NARRATIVE

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Continued from LIC9099

Per HWD, TSPs are temporary services provided by the facility that goes on a resident’s care plan. A resident’s level of care is determined by a point system which is generated into an invoice. Review of facility documents showed that R1 received wound care orders on 02/06/2024 which were not discontinued until 02/27/2024. Facility documents indicated that R1’s Responsible Party received verbal notification on 02/06/2024 that R1’s care level would be affected due to requiring wound care services. On 02/21/2024, R1’s Responsible Party was verbally notified that the wound care services would stay in place since the orders were not discontinued by the Physician. Facility was unable to provide documentation showing that R1’s Responsible Party had received a written notice of R1’s updated service plan with the additional charges included. Therefore, this allegation is Substantiated.

There is an allegation that “Facility did not respond to Representative timely.” Complainant stated that R1’s Responsible Party contacted the facility multiple times to address charges related to R1’s care. Email correspondence provided to LPA indicated that R1’s Responsible Party contacted the facility on 04/04/2024. Responsible party was told that they would have an answer to their inquiry by 04/08/2024. Further correspondence indicated that R1’s Responsible Party followed up on 04/17/2024 and still did not receive a response. Therefore, this allegation is Substantiated.

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 Regional Executive Director. 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: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20240424094747

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/19/2024 Section Cited HSC 1569.657(a)	1 2 3 4 5 6 7	HSC 1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative...written notice of the rate increase within two business days... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to conduct training reviewing the requirements of HSC 1569.657(a) with Managerial Team. Training to include the following: Date of Training, Training Topics, Job Role, Staff Names, and Signatures.
	8 9 10 11 12 13 14	Based on document review and interviews, Licensee did not comply with the section cited above and did not ensure proper notice was provided within two days to resident and/or their responsible party as required. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Training to be submitted to CCL for review and approval by POC due date of 08/19/2024.
Type B 08/19/2024 Section Cited CCR 87468.1(a)(9)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirment is not met as	1 2 3 4 5 6 7	Licensee to submit self-certification stating that they have reviewed the regulation. Certification to be submitted to CCL by POC due date of 08/19/2024.
	8 9 10 11 12 13 14	evidenced by: Based on document review and interviews conducted, facility did not ensure communication with R1’s representative was answered promptly and appropriately as required by regulation. This poses a potential health and saftey risk to residents in care.	8 9 10 11 12 13 14

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

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