486803810-3-21-2022-21-AS-KMOA-CD9QZT-20220407123714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803810
Report Date: 03/21/2022
Date Signed: 03/21/2022 01:30:47 PM

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
09/10/2021 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20210910170333

FACILITY NAME:	COGIR OF NORTH BAY		FACILITY NUMBER:	486803810
ADMINISTRATOR:	DOMIZIO, ANNEMARIE		FACILITY TYPE:	740
ADDRESS:	2261 TUOLUMNE ST		TELEPHONE:	(707) 552-3336
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	83	CENSUS: 44	DATE:	03/21/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Claudia Morales, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained pressure injuries due to neglect
Neglect and lack of supervision
Resident bedroom is not kept in sanitary condition

INVESTIGATION FINDINGS:

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On 3/21/2022 LPA Tobola conducted a complaint investigation for the purpose of delivering findings to the facility. During the course of the investigation, LPA conducted a tour of the facility, made observations, interviewed staff and residents and reviewed facility and resident records.

Complaint alleges resident (R1) sustained pressure injuries due to neglect. Based on interviews and a review of resident (R1's) records LPA found it was indicted in R1's Physician's Report upon admission to the facility that R1 had a history of skin breakdown and ulcers to R1's hip. Upon interviews with staff and a review of hospice records and R1's progress notes, LPA was informed that facility staff provide room checks to R1 every two (2) hours. In addition, staff S1, S2, S3, & S4 stated that R1 is provided repositioning services every two hours.

Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

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-20210910170333

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: 03/21/2022

NARRATIVE

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Complaint alleges neglect and lack of supervision within the facility causing multiple fall incidents for (R1). Based on interviews with staff (S2, S3 & S4) LPA was informed by S2 and S3 that R1 uses a wheelchair and although R1 does have some capacity for self care still requires staff assistance when needed. S2 and S3 also stated that R1 had attempted multiple independent physical tasks regardless of R1's physical limitations and without requesting for staff assistance.

In addition, S4 also stated that on 8/3/2021, S4 observed R1 to have fallen on the bathroom floor. However, R1's Physician's Report dated 6/15/2021 indicted that R1 was able to care for own toileting needs. R1's hospice assessment also stated that R1 was able to transfer self from bed to wheelchair and able to use bathroom without assistance prior to the fall incident.

Complaint alleges resident bedroom is not kept in a sanitary condition. Based on a tour of the facility, tour of multiple resident bedrooms and LPA observations, LPA did not find facility grounds or resident bedrooms to be in an unsanitary condition on this day at the time of visit. LPA was informed by Administrator that housekeeping services are provided once per week or as requested by resident. In addition, based on interview with resident (R2) during a bedroom check, LPA was informed that staff provide timely sanitation service. R2 bedroom also appeared to be in a clean and sanitary condition.

A finding that the complaint allegations, resident sustained pressure injuries due to neglect, neglect and lack of supervision and resident bedrooms are not kept in a sanitary condition are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC9099 (FAS) - (06/04)

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