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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 09/11/2026
Date Signed: 09/11/2026 03:49:22 PM

Document Has Been Signed on 09/11/2026 03:49 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: 57DATE:
09/11/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Resident Care Coordinator, Mari Ramirez, and Executive Director, Kimberly HumphreyTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Resident Care Coordinator, Mari Ramirez. Executive Director (ED), Kimberly Humphrey, arrived during visit at approximately 9:30AM. The purpose of the visit was to to cite a deficiency that was identified during Complaint Investigation, 21-AS-20260522133137 and to follow up on incident reports that were submitted to the Santa Rosa Regional Office (SRRO).

During the course of Complaint Investigation, 21-AS-20260522133137, it was discovered the facility did not submit an SOC-341 report timely per regulation. Review of documentation showed that a suspected incident of abuse between Staff Member 1 (S1) and Resident 1 (R1) occurred on 05/10/2026, and a report was not completed until 05/14/2026. This report was not received by the SRRO until 05/15/2026.

Incident Report 1: SRRO received a report on 07/08/2026. Per report, on 07/05/2026, facility staff heard the facility alarm beeping. Facility staff observed Resident 2 (R2) standing in the facility parking lot. R2 was redirected back into the building and assessed for injury. No injuries were found on R2 and facility made all notifications per regulation.

Review of R2's care plan dated 08/06/2026 showed that they require supervision for their health and safety.

Incident Report 2: SRRO received a report on 07/21/2026. Per report, on 07/20/2026, Resident 3 (R3) was observed to have an open area on their coccyx. R3 was sent to the hospital for further evaluation and facility made all notifications per regulation.

Review of R3's discharge paperwork dated 07/20/2026, showed that R3 was diagnosed with a Stage 2 pressure injury.

Continued on LIC809C
Victoria Bertozzi
Caitlynn Felias
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/11/2026
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Continued from LIC809

SOC-341 Report 1: SRRO received a report on 07/15/2026. Per report, on 07/14/2026, Resident 4 (R4) was walking by Resident 5 (R5) and tried grabbing a shirt that R5 was holding. R5 tried to slap R4 and R4 punched R5 under their eye. Facility staff intervened and redirected both residents. R5 was evaluated for injury and denied having pain. Facility made all notifications per regulation.

SOC-341 Report 2: SRRO received a report on 07/31/2026. Per report, on 07/31/2026, Resident 4 (R4) was observed standing outside of Resident 6's (R6's) room trying to take papers out of their hands. R4 was observed to scratch R6 on their face and chin while trying to get the papers. Facility staff intervened and redirected both residents. R6 was provided first aid and denied having pain. Facility made all notifications per regulation.

SOC-341 Report 3: SRRO received a report on 09/08/2026. Per report, on 09/04/2026, Resident 4 (R4) was standing outside of Resident 7's (R7's) room. When R7 exited they room, R4 pulled on R7's hair with no provocation. R4 and R7 then started to hit each other. Facility staff intervened and redirected both residents. R7 was assessed for injury and was observed to have redness on their hand. R7 denied having pain. Facility made all notifications per regulation.

Per ED, R4 had a one-on-one caregiver until 08/17/2026 because they had an increase in their medications and had been observed to have less behaviors. R4's physician has been contacted regarding R4's medications for review.

Incident Report 3: SRRO received a report on 09/09/2026. Per report, on 09/07/2026, Resident 8 (R8) was observed to be exit seeking. Facility staff redirected R8 and began to reset the facility door alarms. Per report, during this time, R8 exited the facility. Facility staff do not know how R8 was able to exit. After checking the building, facility staff notified emergency personnel. R8 was found by the San Rafael Police Department down the street from the facility. R8 was evaluated for injury and was found to have no injuries. Facility made all notifications per regulation.

Review of R8's Physician Report dated 07/10/2026 showed that they are unable to leave the facility unsupervised.

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, Plan of Corrections, LIC811 (Confidential Names), and Appeal Rights, discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:49 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 09/11/2026 at 02:10 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: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2026
Section Cited
HSC
15630(b)(1)(A)(i)

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Welfare and Institutions Code: 15630(b)(1)(A)(i): "Any mandated reporter who...has knowledge of an incident...shall report...within two working days (A)If the suspected... abuse occurred in a long-term care facility...(i)...report shall be made within two hours of the mandated reporter...obtaining knowledge
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Licensee to submit self-certification that all care staff will receive training on Reporting Requirements by POC due date of 09/12/2026. Licensee to submit proof of training by POC due date of 09/22/2026. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.
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of...physical abuse." Requirement not met as evidenced by: based on record review, and observations, Licensee did not comply with section cited above and did not ensure that R1's suspected abuse was reported timely. This is an immediate health and safety risk to residents in care.
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Type A
09/12/2026
Section Cited
CCR87705(d)

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87705 Care of Persons with Dementia: (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement...This requirement was not met as
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Licensee to submit self-certification that all care staff will receive training on Elopement Training by POC due date of 09/12/2026. Licensee to submit proof of training by POC due date of 09/22/2026. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.
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evidenced by: based on record review, R2 and R8 eloped from the facility. R2 was found in the facility parking lot. R8 was located down the street by the San Rafael Police Department. This poses an immediate health and safety risk to residents in care.
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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