345002909-8-8-2024-59-AS-KHOS-D8AJJV-20240819070609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 08/08/2024
Date Signed: 08/08/2024 11:32:53 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
05/13/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20240513150556

FACILITY NAME:	COGIR OF FOLSOM		FACILITY NUMBER:	345002909
ADMINISTRATOR:	DAVINA BARKER		FACILITY TYPE:	740
ADDRESS:	1801 EAST NATOMA STREET		TELEPHONE:	(916) 608-0800
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	66	CENSUS:	DATE:	08/08/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Deborah Taylor		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee denied resident's hospice worker entry to the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding of the allegtaion cited above. LPA met with Executive Director, Deborah Taylor, and explained the purpose of the visit.

During the course of the investigation, LPA conducted extensive interviews.

Please continue LIC9099-C for the result of the investigation.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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-20240513150556

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: 08/08/2024

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
26
27
28
29
30
31
32

Allegation: Licensee denied resident's hospice worker entry to the facility
The Department conducted extensive interviews. Based on the interview conducted with hospice agency supervisor, it revealed that facility had informed supervisor of potential conflict of interest and asked if hospice nurse will no longer provide services at the facility. Interview revealed that hospice nurse was not denied at the facility to enter. Based on interview conducted with hospice nurse revealed hospice nurse was informed by their supervisor that facility had requested hospice nurse to not return to the facility and hospice agency agreed to comply. Hospice nurse stated they were not denied at the door, the request was asked after a visit. Interview conducted with Executive Director and Health and Wellness Director revealed that the request was made after observations during a visitation and no denial of entry was made.

Based on information above, the department concluded that the allegation is unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies cited.

Exit interview was conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2