345002909-1-13-2025-59-AS-APEZ-DCZPPE-20250117102926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 12/23/2024
Date Signed: 01/13/2025 12:01:52 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
01/16/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20240116142714

FACILITY NAME:	COGIR OF FOLSOM		FACILITY NUMBER:	345002909
ADMINISTRATOR:	PHOEBIE CARCOT		FACILITY TYPE:	740
ADDRESS:	1801 EAST NATOMA STREET		TELEPHONE:	(916) 608-0800
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	66	CENSUS: 34	DATE:	12/23/2024
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Deborah Taylor		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Due to facility staff's lack of care and supervision, resident sustained serious bodily injury
Facility staff's lack of care and supervision resulted in resident's death

INVESTIGATION FINDINGS:

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**This report has been amended**

On January 13, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Executive Director and explained the purpose of the visit.

Throughout the course of the complaint investigation, the Department conducted interviews and reviewed documents relevant to the allegations: due to facility staff's lack of supervision, resident sustained serious bodily injury and facility staff's lack of care and supervision resulted in resident's death.

Please continue on LIC 9099-C (1) for the results of the investigation.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

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-20240116142714

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: 12/23/2024

NARRATIVE

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LIC 9099-C (1)

Note: There has been a change of Executive Director and Health and Wellness Director since the incident.

On January 12, 2024, at approximately 5:35 PM resident (R1) was sent to the emergency room and was discharged back to the community the following day on January 13, 2024, at approximately 5:30 AM. On January 13, 2024, at approximately 12:55 PM, staff observed R1 vomiting and complaint of neck and shoulder pain. Staff sent R1 back to the hospital. Documents indicated that R1 died at the hospital three days later on January 16, 2024. Corners report documented R1’s cause of death to be “probable sepsis” and “acute spinal fracture of T3 and T4 with epidural hemorrhage and acute osteomyelitis with spinal epidural abscess”.

According to statements and interviews conducted, On January 12, 2024, R2 had walked up to the nurse's station and became combative with staff. Staff observed R2 grabbing R1 by the wheelchair and pushing R1 towards the nurse’s station. Staff observed R2 slammed R1 into the nurse’s station door. R2 then pushed R1 down the hallway in their wheelchair. R2 went around the corner with R1 at which time staff heard R1 screaming. Staff came around the corner and observed R1 on the floor. Interviews with staff provided multiple accounts of the incident however, staff present did not attempt to redirect R2 from R1.

The Department conducted interviews with staff which regarding the protocol to take when two residents are having an altercation. Staff indicated they are to redirect and distract residents with something they like. Staff stated when two residents are having an altercation, staff are to intervene and separate the two residents as the safety of residents is a priority.

Based on the information staff provided regarding the altercation between R2 and R1, staff did not follow facility protocols and failed to ensure R1’s wellbeing and safety. Staff indicated R2 had a history of being aggressive physically and verbally. Documents reviewed revealed on October 23, 2023, at approximately 3:30 PM, R2 told another resident in care (R3) to get out of R2's room and pushed R3 down onto the hallway floor.

Please continue LIC 9099-C (2)

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240116142714

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: 12/23/2024

NARRATIVE

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LIC 9099-C (2)

Staff indicated they had expressed concerns to Health and Wellness Director that R2’s medication may need to be adjusted to help with agitation.

File review of R2's physician report revealed R2 has dementia, primary diagnosis of Alzheimer's disease, and with no secondary diagnosis listed. In section Mental Condition, the physician’s report was marked yes for confused/disoriented, inappropriate behavior, and aggressive behavior.

Review of R2's Care Plan Detail signed on January 3, 2024, revealed R2's psychosocial needs stated occasional behavior issues, can become aggressive when R2 wants to leave. Staff are to redirect or let the director know they need assistance.

Interview conducted with Health and Wellness Director revealed when two residents are having an altercation, staff are to intervene and redirect. Staff are to try to get the agitated resident to go on a walk by verbal redirecting cues. Interview revealed that an internal investigation was conducted on January 15, 2024, which revealed staff did not follow facility protocols and did not intervene as trained to do so.

Based on interviews conducted and records reviewed, staff failed to follow facility protocols when there is an altercation between residents. Staff’s failure to ensure R1’s safe and wellbeing resulted in R1 sustaining severe injuries from R2’s actions resulting in R1’s death.

Due to this information obtained, the Department finds the allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty in the amount of $500.00 assessed for R1 sustaining a serious bodily injury while in care at this facility. As a result of the resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess an additional civil penalty if warranted.

Deficiencies cited on the attached LIC 9099-D.

An exit interview was conducted, a copy of the report and appeal rights provided to Executive Director.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240116142714

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: 12/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/24/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	-Licensee is to conduct an audit to identitfy residents with combative behaviors and agitation. POC due within 24 hours on December 24, 2024.
	8 9 10 11 12 13 14	Based on file review and interviews, Licensee did not comply with the section cited above as staff failed to follow protocol during the incident with R2, which poses an immediate health and safety risk for residents in care.	8 9 10 11 12 13 14	- Licensee is provide implementation in care plans for resident’s with aggressive behaviors and state how to ensure staff are aware of the care plans. -Licensee is to provide a training on intervention methods/skills for all staff (regardless of job duty and title) . Licensee is to provide LPA a copy of the training plan. Following information above due January 23, 2025.
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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: 12/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

LIC9099 (FAS) - (06/04)

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