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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002909
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:47:24 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
03/14/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240314145724
FACILITY NAME:COGIR OF FOLSOMFACILITY NUMBER:
345002909
ADMINISTRATOR:PHOEBIE CARCOTFACILITY TYPE:
740
ADDRESS:1801 EAST NATOMA STREETTELEPHONE:
(916) 608-0800
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:66CENSUS: 46DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Deborah Taylor and Shayla HillTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff are mismanaging resident medication.
INVESTIGATION FINDINGS:
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On February 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding of the allegation cited above. LPA met with Executive Director and explained the purpose of the visit.

The Department conducted extensive file review.

Result of the allegation cited above is listed in LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 3
Control Number 59-AS-20240314145724
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: 02/05/2025
NARRATIVE
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Allegation: Staff are mismanaging resident medication.

Based on file review, it revealed R1 was prescribed Levetiracetam 500 mg tablet to be given one tablet by mouth, twice a day, effective date April 3, 2024. File review of R1's e-MAR, it revealed on April 25, 2024, one Levetiracetam tablet was administered at 9 a.m but not at 5 p.m as facility was "waiting refills". On April 26, 2024 at 9 a.m, it was recorded one Levetiracetam was administered, but then at 5 p.m Levetiracetam was not administered due to "waiting for delivery".

Interview conducted with Health and Wellness Director revealed she was not working at the facility during this time in question and cannot explained why one dose was recorded as administered at 9 a.m on April 26, 2024 when it was pending on delivery as stated at 5 p.m.

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. Although the allegation was found to be substantiated, deficiency is not cited as LPA has cited facility for similar allegation in complaint control # 59-AS-20240610163326.

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: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3