216804000-5-8-2023-21-AS-CFES-CRMU9K-20230508152317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:23:28 PM

Document Has Been Signed on 05/08/2023 03:23 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 RAFAEL		FACILITY NUMBER:	216804000
ADMINISTRATOR:	SUSAN EDWARDS		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(415) 472-6530
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70	CENSUS: 50	DATE:	05/08/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director/Administrator, Susan Edwards		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 10:15AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Susan Edwards. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1/SOC-341: CCL received an SOC-341 report on 04/04/2023, and an incident report on 04/11/2023. The reports state that on 03/28/2023, Resident 1 (R1) was observed to be having lunch in the dining room. Resident 2 (R2) was observed to approach R1 during their meal. R2 stated to R1 that they were sitting in their seat. R1 and R2 then started to have an argument. Care staff intervened and R2 was re-directed to another available seat at another table. Later during the meal, R2 was observed to up from their seat and slapped R1 in the face before care staff could intervene again. Care staff continued to monitor the residents during their meal with no further incidents. Facility made all appropriate notifications per regulation. LPA discussed R1 and R2 with Executive Director. Per conversation with Executive Director, R2 has recently had a medication change. As of today, 05/08/2023, Facility has been monitoring R2 and has been communicating with R2's Responsible Party and Physician regarding R2's medication and care. Executive Director also informed LPA that there are no assigned seats during meal times. Incident Report 2/SOC-341: CCL received an SOC-341 report on 04/17/2023 and an incident report on 04/19/2023. The reports state that on 04/14/2023, R1 was observed to be entering the facility's kitchen. Resident 3 (R3) was observed arguing with R1 stating that they cannot enter the facility kitchen. Care staff intervened and re-directed the residents. R3 then approached R1 again and slapped them in the face. Care staff continued to monitor the residents during their meal with no further incidents. Care staff did not observe any injuries. Facility made all appropriate notifications per regulation. LPA discussed R1 and R3 with Executive Director. Per conversation with Executive Director, the facility has rearranged the dining room and have increased staff supervision to deter incidents from occurring. As of 05/08/2023, there have been no further altercations between the residents. Continued on LIC-809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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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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: 05/08/2023

NARRATIVE

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Continued from LIC809

Incident Report 3/SOC-341: CCL received an SOC-341 report on 04/25/2023 and an incident report on 05/04/2023. The reports state that on 04/23/2023, Resident 4 (R4) reported to Evening Care Staff that Resident 5 (R5) pushed himself between R4 and another resident. R5 grabbed R4 by the arm and pushed her. R5 then told R4 to go back to bed in a stern manner. R4 stated that the incident occurred earlier that morning but did not inform Care Staff until that evening. Facility made all appropriate notifications per regulation.

LPA discussed R4 and R5 with Executive Director. Per conversation with Executive Director, R5 was attempting to assist R4 in finding their apartment, stating that they didn't think R4 knew where to go. Facility did not observe any injuries. Facility has been in contact with R4 and R5's Responsible Parties and Physicians. As of today, 05/08/2023, Facility has continued to monitor both residents. R5 had an appointment with their Physician, and no further altercations have occurred.

Incident Report 4/SOC-341: CCL received an SOC-341 report on 05/02/2023 and an incident report on 05/08/2023. The reports state that on 04/30/2023, Care Staff observed Resident 6 (R6) and R1 conversing with each other in the hallway. Care Staff observed a possible argument between the two residents. Before they could intervene, the care staff observed R1 hit R6 on the shoulder. R6 responded by swatting at R1 and hitting them on the arm. Both residents were re-directed and escorted to their rooms. Facility did not observe any injuries. Facility made all appropriate notifications per regulation.

LPA discussed R1 with Executive Director since they were involved with multiple reports that were submitted. Per conversation with Executive Director, R1 and R6 have both recently moved to the community and are still adjusting to their new environment.. Facility has been conducting more status checks for R1. Facility has increased supervision during dining hours and during activities. As of today, 05/08/2023, R1 and R6 have been observed to be at their baseline and have been seen spending time together. No further altercations have occurred.

No Deficiencies Cited during Visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) 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: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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