345002909-3-9-2023-25-AS-LMUZ-CPWTEM-20230314144008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 03/09/2023
Date Signed: 03/09/2023 10:52:47 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20230123162212

FACILITY NAME:	COGIR OF FOLSOM		FACILITY NUMBER:	345002909
ADMINISTRATOR:	EKUNDARE, ADEBIMPE		FACILITY TYPE:	740
ADDRESS:	1801 EAST NATOMA STREET		TELEPHONE:	(916) 608-0800
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	66	CENSUS: 16	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Memory Care Director Wendy Middleton		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff do not ensure facility is free from bed bugs

INVESTIGATION FINDINGS:

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On 03/09/23, Licensing Program Analysts (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Memory Care Director Wendy Middleton. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20230123162212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: COGIR OF FOLSOM	FACILITY NUMBER: 345002909
	VISIT DATE: 03/09/2023

NARRATIVE

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Staff do not ensure facility is free from bed bugs.
An investigation was conducted into the allegation above. Interviews and records reviewed showed that on 12/19/2022, facility staff observed bedbugs in a room at the facility. Upon findings the bedbugs, facility staff showered the resident and relocated the resident in another room. Staff also washed all bedding with hot water and maintenance arrived to bomb the room. The licensee contracted with EcoLab and a Certified Bedbug Dog who came out on 12/20/2022 to assist in irradicating the bedbug infestation. The facility continues to utilize pest control services on a monthly basis. Although the facility did have bedbugs in the facility, the facility took all necessary steps to relocate the resident as well as contact pest control professionals in a timely matter to treat the bedbug room. Based on interviews and document reviews, the facility took steps to ensure the facility was free from bedbugs therefore the allegation is UNFOUNDED. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Memory Care Director and a copy of this report was provided to the facility. The signature of the Memory Care Director on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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