345002909-5-16-2023-25-AS-LMUZ-CRVTKL-20230516144806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:23:22 PM

Unsubstantiated

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
11/16/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20221116072835

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: 15	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Memory Care Director Wendy Middleton		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff shoved a pill into resident’s mouth.
Staff failed to assist resident into bed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On May 16, 2023, 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.

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**

Unsubstantiated

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 25-AS-20221116072835

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: 05/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff shoved a pill into resident’s mouth.
The department conducted record review, interviews, and facility observation to investigate this allegation. From the 3 residents and 5 staff interviews conducted, it has been learned that facility was giving medication to all residents per their doctor orders without any issues. Additionally, it has been learned that facility was not forcing any medications to residents against their will. During department inspections on 11/22/22 and 3/1/23, all staff were attending to resident care needs without any problems. From the record review it has been concluded that facility was documenting medication refusals (if applicable) and notified residents responsible parties and doctors as needed. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

Staff failed to assist resident into bed.
The department conducted record review, interviews, and facility observation to investigate this allegation. From the 3 residents and 5 staff interviews, it has been learned that facility staff was assisting all residents for their ADL care needs per their Needs and Service plan in a timely manner. During department visits on 11/22/22 and 3/1/23 it has been observed that facility staff was attentive to residents’ care needs and all residents appeared to be well groomed and in good care. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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, 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
11/16/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20221116072835

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: 15	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Memory Care Director Wendy Middleton		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff violating resident’s privacy by listening to conversation without consent.
Signal system was not operational.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 25-AS-20221116072835

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: 05/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff violating resident’s privacy by listening to conversation without consent.
During the course of the investigation LPA obtained facility documentation, conducted interviews, and inspected facility grounds. During department visits on 11/22/22 and 3/1/23 it has been observed that residents’ privacy was respected, and no listening devices were observed in residents’ rooms nor was staff being observed around residents’ rooms when family was visiting. Furthermore, no interviews indicated that any residents have any concern with private time with their family members/visitors or experienced any problems in this area. This agency has investigated the complaint alleging staff system was not operational. We have found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Signal system was not operational.
During the investigation LPA obtained facility documentation, conducted interviews, and inspected facility grounds. LPA investigated the allegation, "Signal system was not operational." LPA toured the facility on 11/22/22 and 3/1/23 and observed the call light system was fully operational. During tour staff pulled approximately 3 different call lights in resident rooms and caregivers responded in a timely manner. Staff interviews indicate that call lights are answered within minutes even when other care is being provided. The facility was observed to be equipped with operational pull cords in the resident rooms and bathrooms that are used to notify staff. This agency has investigated the complaint alleging staff system was not operational. We have found that the allegation was UNFOUNDED, meaning that the allegation was 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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4