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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002909
Report Date: 07/25/2024
Date Signed: 07/25/2024 11:58:54 AM


Document Has Been Signed on 07/25/2024 11:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 27DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Deborah Taylor and Davina BarkerTIME COMPLETED:
11:08 AM
NARRATIVE
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On 7/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the LIC 624 Unusual Incident/Injury Report the Department received. LPA met with new Executive Director, Deborah Taylor, and explained the purpose of the visit.

The incident occurred on 7/17/2024 when R1 reported to staff that S1 had threatened R1 to stop utilizing the call light or else S1 will rip the call lights out of the wall. R1 disclosed R1 is afraid to utilize call light after this incident. Facility conducted an investigation and S2 confirmed the incident had taken place as S2 was a witness of the encounter when S1 stated that if R1 does not stop pulling the call lights, S1 will move R1's bed. Facility has since placed S1 on suspension, and S1 is no longer working at the facility. Facility notified Community Care Licensing, Long Term Care Ombudsman and responsible party of this incident.

LPA and Regional Director discussed that S1's last shift was the date of the incident.

As a result of the incident of S1 violating CCR Title 22, Section 87468.1 Personal Rights of Residents in All Facilities, please see LIC 809-D.

Exit interview conducted an a copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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Document Has Been Signed on 07/25/2024 11:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse... This requirement is not met as evidenced by:
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-S1 had been removed from scheduling/ termination.
-Licensee will submit a compliance statement of the cited section by Friday July 26, 2024.
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Based on interview, Licensee did not comply with the section cited above as S2 confirmed that S1 had informed R1 to stop pulling the call light, resulting to R1 being afraid to use call light, which poses an immediate 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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