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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 02/26/2025
Date Signed: 02/26/2025 02:57:24 PM

Document Has Been Signed on 02/26/2025 02:57 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: 49DATE:
02/26/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Business Office Director, Ditter VasquezTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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At approximately 10:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Business Office Director (BOM), Ditter Vasquez. The purpose of the visit was to follow up on an incident report that was self-submitted to Community Care Licensing (CCL).

Incident Report 1/SOC341: CCL received an incident report and SOC341 on 02/25/2025. Reports stated that on 02/21/2025, the facility received a notice from their fall-detection camera system. Facility reviewed camera system which showed Staff Member 1 (S1) grabbing Resident 1 (R1). Reports stated that S1 was shown to be trying to clean R1 after using the bathroom and that R1 was resistant to receiving care. R1 was seen falling backward hitting their head against their bedroom furniture. Reports stated that S1 did not report the fall. On 02/25/2025, Staff Member 2 and Staff Member 3 (S2 and S3) conducted an assessment of R1. Facility made all notifications per Title 22 Regulations. Reports stated that S1 was currently suspended pending internal investigation.

LPA discussed with BOM and facility nurse the importance of having a resident evaluated by medical personnel when a fall occurs and results in a head injury.

LPA obtained additional documentation related to the incident.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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