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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:49:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240610163326
FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:DAVINA BARKERFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 46DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Deborah TaylorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident not receiving medication.
INVESTIGATION FINDINGS:
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On February 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding of the allegation cited above. LPA met with Executive Director and explained the purpose of the visit.

The Department conducted extensive file review.

Result of the allegation cited above is listed in LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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 6
Control Number 59-AS-20240610163326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COGIR OF FOLSOM
FACILITY NUMBER: 345002909
VISIT DATE: 02/05/2025
NARRATIVE
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LIC 9099-C
Allegation: Resident not receiving medication.

The Department conducted extensive file reviews. Based on R1's e-MAR Order Administration Tracking report type of "Recorded As Given", it revealed that Levetiracetam 500 mg was prescribed to be taken one tablet by mouth, twice daily for seizure management. File review revealed on the date of 2nd, 5th, 6th, 14th, 17th, and 22nd of January 2024, only one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA did not observe any reasoning documented as to why resident did not receive medication.

File review revealed on the date of 9th, 20th, and 29th of February 2024, only one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA observed only February 9th, 2024 to have a reasoning of " GIVE ON TIME" but no reasoning documented for February 20th and 29th, 2024.

File review revealed on the date of 2nd of March 2024, no Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA did not observe any reasoning documented as to why resident did not receive medication.

File review revealed on the date of 21st, 25th, and 26th of April 2024, one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA observed "AWAITING REFILLS" and "waiting delivery" to be documented for April 25th and April 26th but no reasoning documented for April 21st.

Due to this information obtained, the Department finds the allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on the attached LIC 9099-D.

An exit interview was conducted, a copy of the report and appeal rights provided to Executive Director.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240610163326

FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:DAVINA BARKERFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 46DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Deborah TaylorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident died due to neglect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the findings for the allegation cited above. LPA met with Executive Director and explained the purpose of the visit.

The Department conducted file review of the following allegation: Resident died due to neglect. File review of R1's Death Report revealed R1 was on hospice services. Based on R1's Death Certificate, R1's cause of death was listed as Cerebral Arteriosclerosis with time internval between onset and death to be listed as "YEARS".

Based on information obtained, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of the report was left at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240610163326

FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:DAVINA BARKERFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 46DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Deborah TaylorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff dropped resident during transfer.
Staff falsified resident records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegation cited above. LPA met with Executive Director and explained the purpose of the visit.

The Department conducted extensive interviews.

Result of the allegation cited above is listed in LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20240610163326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COGIR OF FOLSOM
FACILITY NUMBER: 345002909
VISIT DATE: 02/05/2025
NARRATIVE
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LIC 9099-C

Allegation: Staff dropped resident during transfer.

Based on interview conducted with R1 revealed R1 needed transferring assistance from the commode to a chair when R1 felt weak. R1 stated R1 was then dropped onto the floor. R1 stated it was a male staff assisting R1 with transfer. File review of R1's LIC 602 Physician Report revealed R1 has dementia. Interview conducted with S1 revealed that S1 was working on call in the night shift and assisted R1 with S2. R1 reported R1 felt weak so S1 and S2 provided R1 with a "guided fall" onto the floor to rest until R1 had the strength to stand. File review of the guided fall internal report revealed that R1 sustained a minor skin tear which first aid was administered. The following allegation is unsubstantiated as R1 is unable to recall the story in multiple settings.


Allegation: Staff falsified resident records.

File review of the guided fall internal report revealed S1 and S2 assisted in R1's transfer. Interview conducted with S1 revealed R1 is a two person assist with transfer. The night of the incident S1 was assisting R1 with S2. Interview conducted with R1 revealed R1 does not recall who assisted R1 but does recalled S1 to be in the room. Interview conducted with S2 revealed that S2 does not recalled being in the room with S1 to transfer R1. File review revealed no unusual incident report was submitted to Licensing as the incident was a "guided fall" and R1 did not need medical services. The following allegation is unsubstantiated.

Based on information obtained, the following allegations are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted and a copy of this was report was provided to Executive Director..
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20240610163326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COGIR OF FOLSOM
FACILITY NUMBER: 345002909
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) ... The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee is to submit a plan on how facility will ensure residentsin care are receiving their medications as prescribed. This plan is to be submitted to LPA Yang by February 28, 2025..
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Based on file review, Licensee did not comply to the section cited above as R1 was not administered medications as prescribed, which posed a potential health and safety risk for 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: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6