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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:04:38 PM

Document Has Been Signed on 01/23/2025 04:04 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/
DIRECTOR:		HUMPHREY,KIMBERLYFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(707) 334-1620
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 70CENSUS: 47DATE:
01/23/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Business Office Director, Ditter Vasquez, and Wellness Nurse, Remy Fairbairn, and Executive Director, Kimberly HumphreyTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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At approximately 9:00AM, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to continue a Required 1 Year Visit and met with Business Office Director, Ditter Vasquez, and Wellness Nurse, Remy Fairbairn. Executive Director, Kimberly Humphrey, arrived during visit at approximately 12:30PM. 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, LPAs were informed that there were 47 residents in care and 19 staff members on-site.

LPAs reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed staff and resident files and resident medication. During staff file review, LPAs observed that 5 of 6 staff members did not have current First Aid certification, and 3 of 6 staff members did not have CPR certification (deficiency cited, LIC809D, Health and Safety Code 11569.618(c)(3)). During resident file review, LPAs observed that 1 of 5 residents did not have an updated Physician's Report as required (technical violation issued, LIC9102, regulation 87463(h)). Medication was found to be centrally stored and secure.

As part of their Non-Compliance Plan, LPAs also requested and reviewed documents for all employees hired from November 2024 to January 2025. Review of documents showed that facility hired 5 individuals 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


LPAs followed up on incident reports that were submitted to Community Care Licensing (CCL):

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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
VISIT DATE: 01/23/2025
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Continued from LIC809

Incident Report 1/SOC341: CCL received an incident report and SOC341 on 12/02/2024. Reports state that on 11/25/2024, Staff Member 1 (S1) observed Staff Member 2 (S2) taking Resident 1's (R1) medication card from the facility medication cart. Per reports, S2 also took two Tylenol tablets from R1's medication bottle. Facility conducted an internal investigation and medication audit and found that 42 tablets were missing from R1's medication. Reports stated that facility conducted an in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S2 has since been terminated and is no longer working at facility. LPAs obtained copy of in-service training.

Incident Report 2: CCL received an incident report on 01/23/2025. Report states that on 01/15/2025, Staff Member 3 (S3) observed that Staff Member 4 (S4) did not give Resident 2 (R2) their medication as prescribed on 01/14/2025. Additional documentation showed that R2's medication was documented as given. S2 notified management and a medication audit was conducted (deficiency cited, LIC809D, regulation 87465(a)(4)). Report stated that S4 was suspended pending internal investigation and that facility would receive in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S4 has seen been terminated and is no longer working at facility.

LPAs reviewed Facility's Guardian Roster and confirmed that S2 and S4 have been removed from the facility and are no longer working on-site.

LPAs requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

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, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 04:04 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 01/23/2025 at 03:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above. 5 of 6 direct care staff members did not have current first aid certification. 3 of 6 direct care staff members did not have current CPR certification. This poses an immediate health and safety risk to residents in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee to schedule training with vendor for First Aid/CPR certification for all direct care staff. Licensee to provide training date to CCL by POC due date of 01/24/2025. LIcensee to submit staff roster with job titles and proof of First Aid/CPR certificates to CCL by 02/03/2025.
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above and did not ensure that Resident 2's medication was administered as required. Incident Report stated that R2 did not receive their medication on 01/14/2025. This is an immediate health and safety risk to residents in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee to submit self certification that medication training will be conducted for all staff that administer medications by POC due date of 01/24/2025. Training to include the following: Trainer, Date of Training, Topics, Job Role, Staff Names and Signatures. Proof of Training to be submitted to CCL by POC due date of 02/03/2025.
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
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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