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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 08/19/2025
Date Signed: 08/19/2025 04:36:51 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
07/28/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250728134556
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:
08/19/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Liz CruzTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Licensee did not ensure staff qualified to assigned duties.
Staff mismanaged residents’ medications.
INVESTIGATION FINDINGS:
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On August 19, 2025, Licensing Program Anlayst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Interim Administrator and explained the purpose of the visit.

During the course of this investigation, LPA conducted extensive interviews, file review and medication audit related to: Licensee did not ensure staff qualified to assigned duties; and Staff mismanaged residents’ medications.

Results are as follow in LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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-20250728134556
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: 08/19/2025
NARRATIVE
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LIC 9099-C
Allegation: Licensee did not ensure staff qualified to assigned duties.

The Department conducted a file review which revealed that staff (S1) has been employed with the facility since September 2024 and recently was placed on leave in August 2025. File review of Guardian revealed that S1 required a criminal record exemption in order to work at the facility. A criminal record exemption request was sent to facility on September 21, 2024. Additionally, a letter of case closure was issued on November 18, 2024 due to no response. Live scan was then resubmitted on April 8, 2025 which facility was issued another criminal record exemption request on April 28, 2025 which then a letter for case closure was issued on June 29, 2025 due to no response. Interview revealed that Executive Director was made aware that S1 needed to get the exemption granted in order to work at the facility, but S1 continued to work at the facility until August 2025. The allegation is substantiated as prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall obtain a California clearance or a criminal record exemption.

Allegation: Staff mismanaged residents’ medications.

Based on file review of resident (R1) electronic medication administration records (e-MAR), it revealed that R1 was prescribed pentoxifylline 400MG tablets to take one tablet by mouth daily, effective February 11, 2025. File review of R1's July 2025 and August 2025 e-MAR revealed that on Sunday, August 3, 2025, medication technician failed to administered R1 a dose of pentoxifylline as there is no initials observed. Medication audit was conducted with medication technician of R1's pentoxifylline bubble pack and it revealed that the pack contains 30 tablets. Bubble pack was dated, opened on "7/23/25". From July 23, 2025 to date of visit, August 19, 2025, there should have been 28 tablets given if administered as prescribed but based on medication audit, there was only 27 tablets administered, which confirmed the missing initial on August 3, 2025.

Based on the information obtained, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D.

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

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250728134556
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: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2025
Section Cited
CCR
87411(g)(1)
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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption... This requirement is not met as evidenced by:
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-S1 was immediately removed from schedule. S1 may not return until exemption has been granted.
-Licensee is to conduct an audit of staff roster and file to ensure all individuals working at the facility has a clearance and/or exemption. POC due August 20, 2025
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Based on file review and interview, Licensee did not comply as S1 has been working at the facility since September 2024 when an exemption request has not been completed, which poses a potential risk for residents in care.
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Type B
08/26/2025
Section Cited
CCR
87465()
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance... (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 conduct an in-service for medication technicians to ensure all residents are administered medications as prescribed by physicians.

Proof of in-service is due on August 26, 2025
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Based on file review and medication audit, Licensee failed to comply as R1 was not administered one dose of pentoxifylline as prescribed, which poses a potential risk for resident 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: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3