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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803810
Report Date: 07/31/2023
Date Signed: 07/31/2023 10:33:09 AM

Substantiated


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
07/27/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230727145132
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: 75DATE:
07/31/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tracy FreudendahlTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility elevator is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of investigating this complaint. LPA met with the Administrator, discussed the allegation, tested the elevator. LPA observed that the button on the elevator panel that designates third floor is not functioning properly, although the elevator is still functional. LPA learned that the Administrator has received bids for repair and is awaiting corporate approval for the large expenditure that is needed due to the age of the elevator.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. $1,000.00 civil penalty issued for repeat violation within 12 months.

Report left.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
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-20230727145132
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/21/2023
Section Cited
CCR
87303(a)
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Maintenance and operation. The facility shall be clean, safe, sanitary and in good repair at all times. ***Based on observations, this requirement has not been met as evidenced by: Control button for third floor is not functioning property. This poses immediate risk to safety and personal rights of residents.
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Administration has received bids for repair and is waiting for approval from Corporate Office for the expenditure. Administration to submit proof of repair to CCL by POC date in order to clear the deficiency.
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$1,000.00 Civil penalty issued for repeat violation.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2