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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 05/02/2025
Date Signed: 05/02/2025 11:51:44 AM

Unfounded


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
05/06/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240506103132
FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:PHOEBIE CARCOTFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 48DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Deborah Taylor and Shayla HillTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff left resident unattended for an extended period of time resulting in hospitalization
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
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On May 2, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Executive Director and explained the purpose of the visit.

During the course of this investigation, LPA conducted intensive file reviews and interviews regarding the allegations of the complaint.

The result of the investigation is to follow on LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

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

DATE: 05/02/2025
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 59-AS-20240506103132
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: 05/02/2025
NARRATIVE
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LIC 9099-C

Allegation: Staff left resident unattended for an extended period of time resulting in hospitalization.

File review of R1's medication order on March 13, 2024, it revealed R1 has a previous medical history of hypertension and CKD (chronic kidney disease) stage G3b/A1. Incident report submitted for R1 revealed R1 was sent to the hospital for evaluation due to discoloration around mouth and high temperature. File review of R1's hospital discharge document, it revealed R1 was treated fro acute kidney injury. Document stated the cause of injury may be due to "heart and blood vessel disease". Based on information gathered from R1's physician report it revealed R1 has a primary diagnosis of dementia and secondary diagnosis of atrial fibrillation. Interview conducted with Health and Wellness Director revealed residents in care are checked during rounds every two hours. Health and Wellness Director denied any observation of sunburns on R1. Therefore, allegation is unfounded.

Allegation: Staff are not meeting residents needs

The Department conducted extensive file reviews for the following allegation. File review of R2's care plan conducted on February 22, 2024 revealed R2 is a "one to two" person assist with transfer. File review of R2's care plan conducted on June 13, 2024 revealed R2's level of care has changed which R2 is now a two person assist with mechanical lift. Interview with Health and Wellness Director revealed hospice agency has trained fcaility staff how to use mechanical lift. For new staff, Health and Wellness Director then train staff through demonstration. File review of staff training revealed training was completed by Health and Wellness Director and Suncrest Hospice regarding Safe Transfer with Hoyer Lift, with approximately 17 staff present in attendance. Therefore, allegation is unfounded.

Based on information obtained, the following allegations of: Staff left resident unattended for an extended period of time resulting in hospitalization, and Staff are not meeting residents needs, are UNFOUNDED. Unfounded meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

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

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

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2