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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 03/25/2025
Date Signed: 03/25/2025 11:13:35 AM

Unsubstantiated


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
01/27/2025 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20250127130724
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:
03/25/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ditter VasquezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not provide residents with adequate food service
Staff do not prepare meals in a sanitary manner
Staff do not use soap to wash facility dishes
Staff do not seek medical attention for residents in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. Through interviews, document reviews and unannounced site visits, the following determinations are made: LPA Leibert made unannounced inspections of the kitchen and food service on 2/4/25, 2/27/25, and 3/13/25; Inspections found the dishwasher to be operative with adequate detergent on site; Interviewed staff deny using vinegar to clean dishes; Staff were observed following appropriate sanitation protocols; Facility menus comply with Title Twenty-Two regulations and inspections found food on hand to fulfill the menu requirements; Adequate beverages, snacks, and deserts were observed to be stocked; 2 out of 10 family members asked to comment on food service report satisfaction with the food served; Facility Care Notes for Resident (R1) indicate R1 was sent out on 11/30/24 when observed to be pale with breathing problems; R1 was noted to be at Baseline prior on 11/29; R1 remained out of facility until returning on 1/7/25 and was noted to be at Baseline on 1/9/2025; Care Notes through the rest of January, 2025, indicate some issues addressed by Hospice but no send out for pneumonia and UTI as alleged by Complainant; Continued on next page.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
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 2
Control Number 21-AS-20250127130724
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: 03/25/2025
NARRATIVE
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Staff Nurse denies hearing complaints of pain from R1 prior to the day R1 was sent out for medical care.
Although the allegations may be true, or valid, based upon records reviewed, statements taken, and observations made, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore the complaint is UNSUBSTANTIATED.

No citations issued today.
Report left.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2