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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 08/15/2025
Date Signed: 08/15/2025 05:27:45 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
06/04/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250604120039
FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:TAYLOR, DEBORAHFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 44DATE:
08/15/2025
UNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Lyndee Whaley and Liz CruzTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff's neglect resulted to resident dehydration.
INVESTIGATION FINDINGS:
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On August 15, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to deliver the findings for the allegation cited above. LPA met with Regional Vice President of Operation and Interim Executive Director and explained the purpose of the visit.

Throughout the course of the complaint investigation, the Department conducted interviews and reviewed documents relevant to the allegation: Staff's neglect resulted to resident hospitalization.

Please continue on LIC 9099-C (1) for the results of the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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 3
Control Number 59-AS-20250604120039
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: 08/15/2025
NARRATIVE
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LIC 9099 C

On May 30, 2025, at approximately 5:53 PM, emergency medical services was contacted when staff (S1) found resident (R1) outside on the ground in the courtyard of the facility, R1 was then transported to Mercy Hospital of Folsom Emergency Room for evaluation.

According to hospital paperwork, it revealed R1 was admitted with temperature of 39.1* C (converting to 102.4* F) and "hot to the touch". R1 was discharged at approximately 9:25 PM on May 30, 2025 with reasons for visit to be "heat exposure" due to "the patient had a heat exposure incident related to his care home losing track of him during a fire drill" and discharge diagnosis of heat exposure, dementia, dehydration, and acute kidney injury.

Statements gathered on June 4, 2025, it revealed a fire drill was conducted at approximately 3:00 PM on May 30, 2025, where all emergency exits where released opened. It was revealed that part of the fire drill protocol is for caregivers to conduct a head count on their assigned residents to ensure all residents are accounted for at the end. Additionally, caregivers are to conduct hourly observations on the residents.

Interview conducted with staff (S2) revealed that as a caregiver, S2 is responsible for conducting a head count of the residents, checking to see if the residents are wet and need to be changed, giving the residents showers, participating in activities, transporting the residents to their meals, and getting the residents up for the day or getting them ready to go to bed. Interview indicated a resident head count after the fire drill was not conducted. S2 admitted to losing track of R1 and did not realized R1 was missing until close to dinner time. Staff (S3) then located R1 outside after 5:00 PM.

Based on information obtained, the Department finds the allegation 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. An immediate civil penalty in the amount of $500.00 assessed for R1 sustaining injury and/or illness due to staff's neglect. As a result of the resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess an additional civil penalty if warranted. Deficiencies cited on the attached LIC 9099-D.

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

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

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20250604120039
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: 08/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2025
Section Cited
HSC
1569.319(d)
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§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by:
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In-service training was conducted on June 10, 2025.

Licensee is to update fire drill procedure to ensure staff complete head counts after fire drill completion.

POC is due August 16, 2025.
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Based on interview conducted, Licensee did not comply as R1 managed to escape out of the facility to the locked courtyard, unnoticed for hours by staff, which resulted to an injury, 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
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