486803810-12-8-2025-21-AS-CMAZ-DP8V6N-20251210150946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803810
Report Date: 12/08/2025
Date Signed: 12/08/2025 02:42:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/28/2025 and conducted by Evaluator Elias Magdaleno

COMPLAINT CONTROL NUMBER: 21-AS-20251028103450

FACILITY NAME:	COGIR OF NORTH BAY		FACILITY NUMBER:	486803810
ADMINISTRATOR:	DAVINA BARKER		FACILITY TYPE:	740
ADDRESS:	2261 TUOLUMNE ST		TELEPHONE:	(707) 552-3336
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	83	CENSUS: 54	DATE:	12/08/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Davina Barker, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee not meeting care needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Administrator Davina Barker.

Licensee not meeting care needs – Reporting Party (RP) alleges that facility does not maintain residents room leaving sanitation and fall hazards as well as medication mismanagement. During the course of this investigation LPA reviewed records, made observations, and conducted interviews. Review of Housekeeping Guidelines indicated standard tasks that are expected to be completed by housekeeping. Review of Housekeeping Checklist indicated housekeeping signing off and informing residents of completed cleaning. Review of the assigned task sheet indicated all tasks assigned to specific housekeepers including additional requests or comments from residents. Review of Resident Housekeeping Declination form indicated that residents are able to decline housekeeping services. Review of resident LIC602-Physician Report indicated that resident is capable of storing/administering own medication and has the capacity for self-care.
Continued LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025

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 2

Control Number 21-AS-20251028103450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: COGIR OF NORTH BAY	FACILITY NUMBER: 486803810
	VISIT DATE: 12/08/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099...

Interviews with Housekeeping staff (S1, S2) indicated that resident rooms are split between them and tasks are completed and signed off in the order they are assigned. Further interviews with S1 and S2 indicated that certain residents will ask that only certain tasks be completed and housekeeping will oblige them. Interview with S2 indicated that should they find cleanliness issues not specifically outlined in a resident’s assigned tasks they will clean out of courtesy, as long as the resident agrees. Interview with Administrator indicated there have not been complaints from individual residents regarding housekeeping services. Interview with R1 indicated that facility staff are “really good” and provide assistance when required, however, R1 also stated they are very independent and do not require assistance with medication management or most Activities of Daily Living (ADLs). LPA observed R1 room to be heavily cluttered with objects scattered across the floor and counter tops and a litter box with cat feces. Upon subsequent visits, after R1 agreed to higher levels of cleaning, LPA observed R1’s room to be less cluttered with the floor free of objects and counter tops to be more organized. Although the allegation(s) may have happened or are valid, the Department has found there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated.

No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2