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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 04/11/2023
Date Signed: 04/19/2023 04:15:21 PM


Document Has Been Signed on 04/19/2023 04:15 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:COGIR OF SAN RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR:SUSAN EDWARDSFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(415) 472-6530
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: DATE:
04/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Executive Director, Susan Edwards, and Health and Wellness Director, Victoria MozaffariTIME COMPLETED:
05:00 PM
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At approximately 1:50PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies visit and met with Executive Director, Susan Edwards, and Health and Wellness Director, Victoria Mozaffari. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA also followed up with the facility regarding incidents that were verbally reported to CCL but not submitted to the Department in a timely manner.

Incident Report 1/SOC-341: CCL received an SOC-341 report on 02/16/2023, and an incident report on 02/17/2023. The incident report states that on 02/14/2023, the facility was informed that Resident 1's (R1) Responsible Party reported a possible injury with bruising. Facility spoke with R1 and Responsible Party about the incident and suspended facility staff while an internal investigation was completed. Facility's internal investigation resulted in the facility conducting all staff training. Facility made all appropriate notifications per regulation.

LPA discussed R1 with Executive Director. Per conversation with Executive Director, Local Law Enforcement came to investigate the incident, and determined that no criminal act had occurred. LPA received copies of the two in-service training sheets that were conducted for staff.

Incident Report 2: CCL received an incident report on 03/20/2023. The report states that on 03/15/2023, Resident 2 (R2) was observed being brought back to the facility by a member of the community. Facility was informed by the individual that R2 was located at a nearby restaurant and that they assisted R2 back to the facility. Facility observed that R2's wander bracelet was removed from their wrist. Facility made all appropriate notifications per regulation.

Continued on LIC809
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/11/2023
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Continued from LIC809

Per review of R2's LIC602/Physician's Report, R2 is not allowed to leave the facility unassisted or without facility supervision. Per conversation with Executive Director, R2 was able to leave the facility due to not having their wander bracelet on, and therefore did not trigger the facility's alarm system. Facility has had their alarm system inspected and has ensured that the system is in operating condition. As of today, 04/11/2023, Facility has relocated the wander bracelet to R2's ankle and they have not left the facility unassisted since.

LPA also followed up on two Death Reports and two Incident Reports that were verbally reported to the Department but were not submitted in a timely manner. LPA requested to have the reports submitted on the following dates: 03/07/2023, 04/03/2023, 04/04/2023, and 04/05/2023. On 04/06/2023, LPA received one of the incident reports that had been requested. During today's visit, 04/11/2023, LPA received copies of the death reports and other incident report that had not been submitted.

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.

***An immediate civil penalty in the amount of $1,000.00 has been issued for a repeat violation of
the California Code of Regulations (CCRs) Section 87211.

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC421IM (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/19/2023 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited

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87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia...(2)Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
This requirement was not met as evidenced by:
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Licensee to submit receipt of alarm system inspection by POC date of 04/12/2023. LPA was provided with a copy of receipts during visit. POC cleared.
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Based on review of documents, the Licensee did not comply with the section cited above. Resident was found outside of the community without facility supervision and is unable to leave unassisted. This poses an immediate health, safety or personal rights risk to residents in care.
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Type B
04/21/2023
Section Cited

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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...
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Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements. 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 04/21/2023.
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This requirement was not met as evidenced by: Based on interviews conducted and email correspondence, the Licensee did not comply with the section cited above. Licensee did not submit incident or death reports to CCL in a timely manner. This poses a potential 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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