216804000-6-30-2023-21-AS-CFES-CTATW5-20230630150459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 06/30/2023
Date Signed: 06/30/2023 03:05:03 PM

Document Has Been Signed on 06/30/2023 03:05 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: 52	DATE:	06/30/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator/Executive Director, 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 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Administrator/Executive Director, Susan Edwards. The purpose of the visit is to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL), to review the plan of corrections submitted to CCL, and to schedule a Non-Compliance Conference. SOC-341 Report 1: CCL received an SOC-341 report on 05/22/2023. The report stated that on 05/21/2023, Resident 1 (R1) and Resident 2 (R2) were observed exiting the facility elevator together. R1 was seen to be observing R2's purse when R2 slapped R1 with their open hand. Care staff immediately separated the two residents. Facility made all appropriate notifications per regulation. Incident Report/SOC-341 Report 2: CCL received an SOC-341 report on 06/23/2023. The report stated that on 06/22/2023, R2 and Resident 3 (R3) were attending a dance activity. R2 was dancing and touched the shoulder of R3. R3 pushed R2 causing R2 to fall foward. R2 stopped their fall by catching the back of a chair. Care staff immediately separated the two residents. Facility made all appropriate notifications per regulation. LPA discussed all Residents with Executive Director. Per conversation with Executive Director, Facility has increased staff supervision to help minimize incidents from occurring. Facility also conducted In-Service Training on the following topics: Resident Care Plans - Learning about Individuals and Sitting Residents Safely. LPA was informed that staff reviewed Resident behaviors and triggers and how to navigate those situations. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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: 06/30/2023

NARRATIVE

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Continued from LIC809

LPA also discussed the Plan of Corrections related to Complaint Investigation dated for 09/12/2022, and the Case Management visit conducted on 06/02/2023. The following deficiencies were cited on 06/02/2023:

Personal Rights 87468(a)
Incidental Medical and Dental Care 87465(g)
Welfare and Institutions Code Section 15630(b)(1)(A)(i)
Administrator - Qualifications and Duties 87405(a)

Facility completed and submitted all documentation to CCL timely. Facility submitted Certification to CCL which stated that that staff training would be conducted on the following topics: Personal Rights, Incidental Medical and Dental Care, Reporting Requirements, and Administrator of Facility along with the Designated Representative. Facility submitted completed training documentation on 06/12/2023 to CCL.
The above deficiencies have been cleared during today's visit.

**A Non-Compliance Conference has been scheduled for July 12, 2023 between the Facility and CCL.

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: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

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