486803809-2-2-2024-21-AS-VBEI-D342D7-20240305161751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803809
Report Date: 02/02/2024
Date Signed: 02/02/2024 05:10:40 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240129151241

FACILITY NAME:	COGIR OF VACAVILLE		FACILITY NUMBER:	486803809
ADMINISTRATOR:	STOUDER, ROBIN		FACILITY TYPE:	740
ADDRESS:	799 YELLOWSTONE DRIVE		TELEPHONE:	(707) 447-7496
CITY:	VACAVILLE	STATE:	ZIP CODE:	95687
CAPACITY:	49	CENSUS: 34	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Robin Stouder, Administrator		TIME COMPLETED:	05:09 PM

ALLEGATION(S):

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Personal rights: Sexual abuse

INVESTIGATION FINDINGS:

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At approximately 1:40 PM, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to deliver the results from an investigation on the above allegation.
LPA met with Administrator Robin Stouder. The investigation included interviews with staff, family members and a review of records which showed resident was not sexually assaulted. Staff documentation and interviews conducted with family showed that resident has expressed on multiple occasions, for several years, the same symptoms.

Continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240129151241

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF VACAVILLE	FACILITY NUMBER: 486803809
	VISIT DATE: 02/02/2024

NARRATIVE

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Continued from 9099...

On 01/ 27/24 at approximately 5:30 PM, resident pressed pendant and presented that they were in severe pain and wanted to go to hospital. Resident was taken to the hospital to address their concerns. While in the Emergency Room resident stated that a staff member had sexually abused them. Resident was seen by physician, whose diagnosis was acute urinary retention and rectal pain. Exam did not report any sexual penetration. Resident received a prescription and instructed to schedule an appointment with their primary care physician and was discharged at 11:22 PM, 1/27/24. Resident returned to facility. Interviews with Family Member 1 (FM1) and Family Member 2 (FM2) state that the resident does not remember making the allegation of sexual abuse while in the Emergency Room, and was only seeking treatment for their pain and discomfort, and recanted the allegation to both FM1 and FM2.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unfounded.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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