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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002909
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:22:33 PM


Document Has Been Signed on 06/12/2024 04:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:DAVINA BARKERFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 22DATE:
06/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Shayla Hill and Davina BarkerTIME COMPLETED:
02:15 PM
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On 06/12/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received on 6/11/2024. LPA met with Interim Executive Director and Health Wellcare Director Nurse and explained the purpose of the visit.

According to the incident report received, it stated local law enforcement arrived to the facility on 6/10/2024 to conduct a welfare check on R1 due to a recent fall R1 sustained.

LPA, Executive Director and Health Wellcare Director Nurse discussed the following incident. LPA was informed by Health Wellcare Director Nurse that on 6/3/2024 R1 had a "guided fall" at approximately 2:40 AM. Health Wellcare Director Nurse informed LPA that in the middle of a transfer between Health Wellcare Director Nurse, S1 and R1, R1's legs became weak and needed to be placed on the floor temporarily to rest before Health Wellcare Director Nurse and S1 assisted R1 back to the commode. After R1 was placed back on the recliner, Health Wellcare Director Nurse provided first aid to R1 as R1's elbow was observed to have a skin tear.

When asked for the incident report of the incident, Health Wellcare Director Nurse informed LPA LIC624 was not created and submitted as R1 did not have a fall, it was a guided fall, and no injury was sustained, R1 was not sent to the hospital. LPA was provided a copy of internal incident report.

This incident is currently under review, No deficiencies cited today.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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