216804000-12-13-2022-21-AS-KMOA-CMRRJ7-20230104120328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:20:48 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/05/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20221205093030

FACILITY NAME:	COGIR OF SAN RAFAEL		FACILITY NUMBER:	216804000
ADMINISTRATOR:	DOWELL, CAROL		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(415) 472-6530
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70	CENSUS: 77	DATE:	12/13/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Executive Director, Susan Edwards		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not properly report incidents.

INVESTIGATION FINDINGS:

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At approximately 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Executive Director, Susan Edwards.

During the course of the investigation, LPA Felias reviewed and requested documents, made observations, and conducted interviews. There is an allegation that facility staff did not properly report incidents. Based on interviews conducted, there have been instances where Residents were found to be stuck in the facility elevator for as long as ten minutes. Document review indicated that facility did not report these incidents to Community Care Licensing (CCL). The allegation that facility staff did not properly report incidents is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Continued on LIC-9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/05/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20221205093030

FACILITY NAME:	COGIR OF SAN RAFAEL		FACILITY NUMBER:	216804000
ADMINISTRATOR:	DOWELL, CAROL		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(415) 472-6530
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70	CENSUS: 77	DATE:	12/13/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Executive Director, Susan Edwards		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility elevator in disrepair.

INVESTIGATION FINDINGS:

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At approximately 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegations and met with Executive Director, Susan Edwards.

During the course of the investigation, LPA Felias requested and reviewed documents, conducted interviews, and made observations. There is an allegation that Facility elevator in disrepair. Information provided to LPA indicated a concern that the elevator breaks down resulting in Residents getting stuck. Invoices dated 9/30/2022, 10/31/2022, and 11/30/2022 showed that the facility conducted regular and scheduled maintenance for the elevator through Capitol Elevator Company. Invoices dated 6/30/2022, 7/12/2022, 9/26/2022, and 11/28/2022 show that the facility contacted the company to replace or fix parts of the elevator. Invoice dated 11/28/2022, indicated that the facility contacted the repair company due to the elevator trapping people. Invoice stated that the Repair Mechanic tested and returned the elevator to normal service.

Continued on LIC-9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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 5

Control Number 21-AS-20221205093030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 12/13/2022

NARRATIVE

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Continued from LIC-9099

Interviews conducted indicated that the elevator has been needing repairs frequently, and that residents have been stuck in the elevator before. During visit, LPA used the elevator that was alleged to be in disrepair. LPA observed that the elevator was operating and functional at approximately 10:45AM, 11:35AM, and 1:30PM. Based on review of documents, interviews, and observations made, the allegation that facility elevator is in disrepair is Unsubstantiated. A finding that the complaint 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.

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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20221205093030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 12/13/2022

NARRATIVE

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Continued from LIC-9099

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted. Plan of Corrections reviewed and developed with Executive Director. Copy of report, LIC 9099-D, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 21-AS-20221205093030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 12/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/23/2022 Section Cited CCR 87211(1)(a)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D) Any incident which threatens the welfare, safety or health of any resident...	1 2 3 4 5 6 7	Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 12/23/2022.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews conducted and review of documents, the Licensee did not comply with the section cited above, and did not submit reports to CCL when residents were found stuck in the elevator for an extended period of time. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
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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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC9099 (FAS) - (06/04)

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