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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 09/10/2025
Date Signed: 09/10/2025 02:51:13 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
02/25/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250225082520
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: 43DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Liz Cruz and Karen SilvaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not update resident's medical records.
INVESTIGATION FINDINGS:
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On September 10, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue a complaint investigation and deliver the finding.

LPA met with the Regional Executive Director and the Regional Director of Health and Wellness.

During the course of this investigation, LPA conducted interviews and file reviews. The result of the investigation is as follows in LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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 7
Control Number 59-AS-20250225082520
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: 09/10/2025
NARRATIVE
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LIC 9099-C

Allegation: Staff did not update resident's medical records.

The department conducted extensive interviews regarding the allegation cited above. An interview conducted with the reporting party revealed that R1 has been switched from Kaiser Permanente to Mercy Health effective January 1, 2025, which the facility was notified and provided with an updated medical card. An interview conducted with the Health and Wellness Director on March 7, 2025, revealed that the resident (R1) was sent out to Kaiser Permanente Roseville for evaluation due to leg pain. The Health and Wellness Director stated a new medical card was provided; however, it was not updated on the chart, therefore, R1 was sent to the wrong medical facility for evaluation. Based on R1’s identification and emergency information, it revealed that R1’s hospital to be taken in an emergency was previously written as “Kaiser Roseville” and then crossed out with new input of “Mercy Folsom”. File review of hospital discharge paperwork and progress notes revealed that R1 was sent out to Kaiser Roseville for evaluation.

Based on the information obtained, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Please see LIC9099-D.

Exit interview conducted, copy of report and appeal rights was provided.

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

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
02/25/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250225082520

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: 43DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Liz Cruz and Karen SilvaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident falling.
INVESTIGATION FINDINGS:
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On September 10, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue a complaint investigation and deliver the finding.

LPA met with the Regional Executive Director and the Regional Director of Health and Wellness.

During the course of this investigation, LPA conducted interviews and file reviews. The result of the investigation is as follows in LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20250225082520
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: 09/10/2025
NARRATIVE
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LIC9099-C

Allegation: Staff did not provide adequate supervision resulting in resident falling.

Based on file review of resident’s (R1) progress notes, it revealed that R1 was transported to the emergency room for evaluation due to leg pain. No further indication of a fall. An interview conducted with R1’s responsible party revealed that facility staff have alleged two separate statements that R1 had a fall while in the shower; however, also being informed that R1 did not have any fall in the shower. The interview conducted with Health and Wellness Director on March 7, 2025, revealed that R1 has showering assist getting in and out of the shower, but there is no reporting of R1 sustaining a fall in the shower.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with administrator.

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

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
02/25/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250225082520

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: 43DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Liz Cruz and Karen SilvaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident.
Staff did not notify resident's responsible party of incident.
Facility AC/Heater wall unit is in disrepair and accessible to residents.
INVESTIGATION FINDINGS:
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On September 10, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue a complaint investigation and deliver the finding.

LPA met with the Regional Executive Director and the Regional Director of Health and Wellness.

During the course of this investigation, LPA conducted interviews and file reviews. The result of the investigation is as follows in LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20250225082520
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: 09/10/2025
NARRATIVE
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LIC 9099-C

Allegation: Facility AC/Heater wall unit is in disrepair and accessible to residents.

On February 25, 2025 the Department received the complaint with the allegation cited above. On March 7, 2025, the Department conducted an inspection of the facility's air conditioning unit located at the end of the common area. Based on observation, the air conditioning unit was operating and in good condition. There was no observation of the air conditioning unit being a danger to residents in care.

Allegation: Staff did not seek medical attention to resident.

Based on file review of the resident’s (R1) progress notes, it revealed that R1 was experiencing pain at approximately 4:30 AM and was given PRN medication. Approximately an hour later, R1 continued to express leg pain which facility then contacted emergency medical services. File review of R1’s hospital discharge paperwork revealed X-rays were taken and found to be normal and discharged at approximately 12:52 PM.

Allegation: Staff did not notify resident's responsible party of incident.

Based on file review of the resident’s (R1) progress notes documented by medication technical, it revealed that R1 was experiencing pain at approximately 4:30 AM and was given PRN medication was administered. Follow up notes revealed R1 continued to express pain which facility then contacted emergency medical services, and then notified Health and Wellness Director and R1’s responsible party.

Based on the information above, the department concluded that the allegations are 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.

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

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

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20250225082520
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: 09/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2025
Section Cited
CCR
87506(b)(9)
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87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
(9) Name, address and telephone number of physician and dentist to be called in an emergency.
This requirement is not met by:
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Licensee is to submit a procedure of how facility will update residents medical information as needed to ensure resident records remain accurate.

POC is due September 30, 2025.
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Based on file review and interview, Licensee did not comply as R1's resident record did not have R1's updated medical physician information which R1 was transported to wrong emergency medical facility which poses a potential risk for resident in care.
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As a reminder, failure to correct by plan of correction due date may result to $100 per day until corrected.
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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: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7