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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 04:36:20 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
06/23/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250623112243
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:
02:16 PM
MET WITH:Liz CruzTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff did not ensure that resident was administered their medications as instructed by their physician.
INVESTIGATION FINDINGS:
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On August 19, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the findings of the allegation cited above. LPA met with Interim Administrator and explained the purpose of the visit.

For the allegation of staff did not ensure that resident was adminstered their medications as instructed by their physician. The Department conducted extensive file reviews and medication audit to investigate the allegation.

Please continue on LIC 9099-C to see the result of the investigation.
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-20250623112243
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: Staff did not ensure that resident was administered their medications as instructed by their physician.

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 allegations cited above are substantiated, but no deficiency will be as LPA substantiated the similar allegation for Complaint #59-AS-20250623112243 on August 19, 2025.

Exit interview conducted, copy of 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: 3 of 3