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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 09/26/2024
Date Signed: 09/26/2024 02:56:42 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
09/17/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240917095150
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: 31DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Deborah TaylorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff served expired food to residents
INVESTIGATION FINDINGS:
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On 9/26/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open and deliver the finding of the allegation cited above. LPA met with Executive Director and explained the purpose of the visit.

During the course of today's investigation, LPA conducted an inspection of the facility walk-in refrigerator and the facility dry pantry storage. Additionally LPA conducted an interview with Executive Director.

The result of the investigation for the allegation is as follow on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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-20240917095150
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: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a) The total daily diet shall be of the quality...necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
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Licensee is to submit a plan how to ensure residents in care are not given expired food.

POC due to LPA Yang by due date of 10/04/2024.
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Based on kitchen inspection, Licensee did not comply with the section cited above as LPA observed two items in the pantry that was expired, which poses a potential health, safety, and personal rights violation to the 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: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240917095150
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: 09/26/2024
NARRATIVE
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LIC 9099-C

Allegation: Facility staff served expired food to residents

The Department conducted a kitchen inspection, file review and interviews regarding the following allegation. Interview conducted with Executive Director revealed that a photo was circulating around the facility of an expired salad dressing. Executive Director stated the bottle itself did not have an expiration date, only a manufactured date but there may have been some discoloration on the dressing container. File review of the incident report received by the Department on 9/20/2024 revealed "upon inspection of the kitchen we did find the expired salad dressing and properly disposed". Kitchen inspection conducted on 9/26/2024 revealed that in the facility dry pantry storage, Hollandaise Sauce Mix was observed on the shelf with best by date of "JAN2724" indicating January 27, 2024. Inspection further revealed a jar of peanut butter to be on the shelf with best if used by date of "SEP0424" indicating September 4, 2024. Based on observing the following food items, the allegation is substaniated.

Based on the information obtained for the allegation, facility staff served expired food to residents, 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. The following allegation cited above is substantiated, please see LIC9099-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3