486803810-10-30-2023-21-AS-KMOA-CXLMTY-20231115085415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803810
Report Date: 10/30/2023
Date Signed: 10/30/2023 11:47:25 AM

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
10/19/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20231019125734

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: 64	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Tracy Fruedendahl		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Residents needs are not being met by facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation included site visits to the facility; statements taken from witnesses and parties; as well as review of documents obtained during the course of the investigation. It has been alleged that the facility has not met R1's needs in that R1 has missed medical appointments; has not set up R1's voice mail; and does not wear a durable medical device prescribed following surgery because staff do not assist R1. The following determinations are made: R1 lives relatively independently with occasional transportation provided by the facility and has not contracted with the facility for additional care; R1's care plan and physician's assessment indicate R1 does not need assistance with activities of daily living; R1's states that R1 has chosen to not attend appointments or wear the medical device on occasions in the recent past. Although the allegation may be true, based on statements and documents reviewed, there is not a preponderance of evidence to prove the allegation is or, is not, true. Therefore, the allegation is UNSUBSTANTIATED.
Report left.
No citations issued today.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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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