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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803810
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:06:58 PM

Unsubstantiated


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
11/03/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20221103162806
FACILITY NAME:COGIR OF NORTH BAYFACILITY NUMBER:
486803810
ADMINISTRATOR:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:2261 TUOLUMNE STTELEPHONE:
(707) 552-3336
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:83CENSUS: 38DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Dina Lopez, Health Services DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility staff failed to safeguard resident's funds
INVESTIGATION FINDINGS:
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On 2/9/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and was greeted by Health Services Director, Dina Lopez. LPA toured the facility, reviewed staff and resident records, conducted interviews with staff and made observations.

Complaint alleges facility staff failed to safeguard resident's (R1) funds. Based on a review of records, all caregiving staff that may have provided care to R1, did not have addresses matching the home address indicated of the alleged abuser. In addition, based on interviews with Health Service Director (HSD) and a review of R1’s records, LPA found that R1 was not able to handle their own finances and has a Power of Attorney in charge of their finances.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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 2
Control Number 21-AS-20221103162806
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 NORTH BAY
FACILITY NUMBER: 486803810
VISIT DATE: 02/09/2023
NARRATIVE
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Lastly, based on a review of records, LPA found that the start date of fraudulent activity under resident's (R1) bank account began on 8/23/2022. However, resident (R1) had not been admitted into Cogir of North Bay until 9/8/2022, therefore the allegation is found to be unsubstantiated.

Allegation, facility staff failed to safeguard resident's funds is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.

No deficiencies cited during visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2