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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 03/14/2025
Date Signed: 03/14/2025 02:26:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
03/06/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250306172541
FACILITY NAME:COGIR OF SAN RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR:HUMPHREY,KIMBERLYFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(707) 334-1620
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: 50DATE:
03/14/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Executive Director, Kimberly Humphrey TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility's emergency call system was in disrepair
INVESTIGATION FINDINGS:
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At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegations and met with met with Executive Director/Administrator, Kimberly Humphrey.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of "Facility's emergency call system was in disrepair.” Complainant alleged that there were many occasions that the facility's pull cords were not functional and that facility staff were not receiving the calls on their pagers.

Interview conducted with Executive Director stated that the facility's call system was not working approximately four weeks ago and was fully repaired this past Monday, 03/10/2025. Per Executive Director,

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
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 3
Control Number 21-AS-20250306172541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/14/2025
NARRATIVE
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Continued from LIC9099

residents' calls were still showing up on the facility's monitors if a resident's pull cord or resident pendant was used. Executive Director stated that issue was that the system was not allowing new pendants to be programmed and therefore current residents that required a replacement pendant were unable to receive one. Facility contacted their Call System company, Lifeline Senior Living, to have a systems technician conduct a repair. Per Executive Director, as of Monday, 03/10/2025, the facility's call system has been updated, all pull cords and resident pendants have been checked to ensure they are fully functioning/operable. Executive Director stated that when the system was malfunctioning, care staff were doing increased checks on residents.

LPA conducted staff interviews. 4 of 5 interviews conducted stated that resident pull cords have not been working as expected and that sometimes they do not receive the calls on their pagers. Interviews conducted revealed that they have been told it's a problem with the system and that management has been working on getting it resolved.

Review of facility documents showed that Lifeline Senior Living provided a quote of repairs to the facility on 03/04/2025.

Based on interviews conducted and document review, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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, LIC9099D (Deficiency Page), 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: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250306172541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2025
Section Cited
CCR
87303(i)(1)(A)
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87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and...separate floors or buildings shall have a signal system...(A) Operate from each resident's living unit.
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Facility to submit the following documents: Lifeline Senior Living Receipt of Repairs and Audit of Resident Pull Cords to be done by Maintenance Director to ensure that they are operable. Documents to be submitted by POC due date of 03/24/2025.
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This requirement was not met as evidenced by: based on interviews and document review, Licensee did not comply with the section cited above and did not ensure that facility's pull cord system was operating as required. 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3