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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 06/23/2026
Date Signed: 06/23/2026 04:13:34 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
11/05/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20251105134928
FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:CRUZ, ELIZABETHFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 45DATE:
06/23/2026
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Karen Silva, Regional Health and Wellness DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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-Facility staff did not provide resident's authorized person resident records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Regional Health and Wellness Director, Karen Silva, to deliver complaint investigation findings regarding the above stated allegation.
LPA obtained email correspondence between resident (R1's) responsible party and facility staff. On October 30, 2025, R1's responsible party requested R1's resident records, which included incident reports and any required state notifications or reports made after R1's passing. On October 31, 2025, the facility provided R1's responsible party with R1's resident records. However, the records were missing R1's Death Report LIC624A, which should have also been reported to CCLD within seven (7) days of occurrence. The facility was unable to provide proof that the Death Report was provided to R1's responsible party or to CCLD.
Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.
Exit interview conducted. A copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
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 4
Control Number 59-AS-20251105134928
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: 06/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2026
Section Cited
CCR
87211(a)(1)(A)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement is not met as evidenced by:
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Facility shall submit a statement of understanding to LPA by the POC due date of 7/7/2026.
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Based on records reviewed, the facility did not ensure that resident (R1's) Death Report was provided to CCLD and R1's responsible party within seven (7) days of occurrence, which poses a potential health, safety, and personal rights risk to 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: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/05/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20251105134928

FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:CRUZ, ELIZABETHFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: DATE:
06/23/2026
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Karen Silva, Regional Health and Wellness DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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-Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Regional Health and Wellness Director, Karen Silva, to deliver complaint investigation findings regarding the above stated allegation.

During the course of the investigation, interviews were conducted and documentation was obtained pertinent to the investigation.


**********************************************Continued on LIC9099-C*****************************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
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 4
Control Number 59-AS-20251105134928
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: 06/23/2026
NARRATIVE
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The Final Autopsy Report for resident (R1) indicated that the diagnoses are as follows: edema, electrical cardiac event, and severe emphysema with organizing bronchopneumonia. The Sacramento County Coroner Report indicated that the cause of death was determined to be Citalopram and Memantine Toxicity, as well as hypertension cardiovascular disease and obesity. The report also indicated that “it is unclear how the toxicity occurred. The decedent’s medications were reportedly controlled by the care facility. There were no reports of suicidal ideations. No suspicious circumstances were found. Based on the circumstances and cause of death, the manner will be listed as Undetermined”. The Toxicology Report indicated that R1 had 620 ng/ml of Citalopram/Escitalopram and 380 ng/ml of Memantine. Interview with Sacramento County Coroner’s Office representative indicated that they did not know if the medication toxicity was due to an overdose or R1’s poor metabolism. Interview indicated that R1’s age could have played a role in their body’s ability to metabolize medication. They also noted that R1 had hypertension and obesity, which increased the risk of having a sudden cardiac arrest. Facility staff did not report any changes in R1’s baseline leading to their death. Staff interviews indicated that R1 did not have a history of pocketing medications, and there were no indications of R1 entering the locked medication room and taking medications.

Based on documentation obtained and interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4