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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803807
Report Date: 07/29/2025
Date Signed: 07/29/2025 05:09:14 PM

Substantiated


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
07/07/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250707151553
FACILITY NAME:COGIR OF ROHNERT PARKFACILITY NUMBER:
496803807
ADMINISTRATOR:ORDING, KELLYFACILITY TYPE:
740
ADDRESS:4855 SNYDER LANETELEPHONE:
(707) 585-7878
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:75CENSUS: DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kelly Ording-AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Unqualified adult providing residents' medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 7/29/25 at approximately 9:45am, and met with the Administrator, Kelly Ording, and Tamra Richmond, Business Office Manager.

Reporting party alleges "unqualified adult providing residents' medications". LPA requested specific records regarding staff (S3); LPA requested a copy of the facility's policy regarding agency staff and/or private companions in the building. LPA requested documentation of staff S3's qualifications to work in the facility, staff/agency file documents, including medication training.

Per interview with Administrator, staff S3 worked two shifts for the facility assisting residents with medications in July 2025; Administrator stated S3 worked previously at the facility, but now has their own staffing agency. LPA discussed the facility's responsibility in providing all care, assisted daily living needs (ADL's), to the residents' in the facility. Ensuring resident's current care needs are provided/met by the facility staff.
Per interview with S3, they used to work at the facility assisting residents' with medications but left to start an agency for care staff. LPA requested a business card, but S3/ staff stated they didn't have one to provide the LPA.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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 4
Control Number 21-AS-20250707151553
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 ROHNERT PARK
FACILITY NUMBER: 496803807
VISIT DATE: 07/29/2025
NARRATIVE
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Continued from LIC9099, dated 7/29/2025..
Per interview with S3, they used to work at the facility assisting residents' with medications but left to start an agency for care staff. LPA requested a business card, but S3/ staff stated they didn't have one to provide the LPA.

LPA requested Administrator to provide documents on file regarding S3 as a staff of the facility and/or documents as an agency registry staff in the facility providing services.
Administrator stated they didn't have any agency staff documents on S3, but have repeatedly requested required documentation from S3, and S3 has never provided it to the facility. Administrator stated they would see what documents they have on former staff S3, and will request S3 to complete required documentation to them. Administrator stated they would provide records on S3's qualifications, and their agency/registry documentation to the LPA. Records were provided to the LPA.

Per review of records, staff interviews, and obtained information, the investigation revealed, S3 last completed required medication training hours on 11/11/2023 and 11/12/2023. This is out of compliance with health & safety code requirements, there is initial medication training hours required, including medication shadowing hours, and medication training annually. This deficiency will be cited, HSC1569.69(a)(1)(b) Employees assisting residents with self-administration of medication; training requirements, see LIC9099D.

Per review of Guardian, criminal record clearance database, S3 is not associated to the facility and was separated by Cogir of Rohnert Park on 12/5/2023. It was also identified that S3's fingerprint clearance was separated from North Bay Home Care agency on 10/9/2024, and separated from North Bay Home Care, INC. agency on 2/18/2025. This is out of compliance with title 22 regulation requirements, 87355(e)(2)(3) Criminal Record Clearance, it will be cited, see LIC9099D.

There was sufficient information obtained to support that a violation occurred regarding the allegation. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.
Exit interview conducted with the Administrator Kelly Ording.
Appeal Rights Provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/07/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250707151553

FACILITY NAME:COGIR OF ROHNERT PARKFACILITY NUMBER:
496803807
ADMINISTRATOR:ORDING, KELLYFACILITY TYPE:
740
ADDRESS:4855 SNYDER LANETELEPHONE:
(707) 585-7878
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:75CENSUS: DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not provide resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 7/29/25 at approximately 9:45am, and met with the Administrator, Kelly Ording, and Tamra Richmond, Business Office Manager.

Reporting party alleges "staff did not provide resident's medication as prescribed". In review of the information provided regarding the allegation, there was no information identifying the resident, name unknown; There was no medication information provided in order to review how medication was provided to the resident. LPA was not able to identify the resident's medication records to review as part of the investigation. LPA reviewed a sample of medication records, three (3) files. There was no information obtained to support that a violation occurred regarding "staff did not provide resident's medication as prescribed".

Based on the investigation, the allegation "staff did not provide resident's medication as prescribed" is Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
No deficiencies cited.
Exit interview was conducted with the Administrator Kelly Ording.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250707151553
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 ROHNERT PARK
FACILITY NUMBER: 496803807
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2025
Section Cited
HSC
1569.69
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HSC1569.69(a)(1)(b) Employees assisting residents with self-administration of medication; training requirements-Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training, including 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. Each employee required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training in each succeeding 12-month period
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Licensee to ensure all facility staff have required medication training per HSC1569.69, including any appropriately cleared agency staff that are assisitng residents' with medications. Licensee to submit written plan of future facility compliance regarding HSC requirement by all staff assisitng residents' with medications.
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This requirement was not met as evidenced by:Per review of records, the investigation revealed, S3 last completed required medication training hours on 11/11/2023 and 11/12/2023. This is a health & safety risk to residents' in care.
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POC due 7/30/2025.
Note: In addition to the above, If facility hires S3 to work in the facility, and they handle medications, submit completed HSC medication proof of training, and update employee roster, LIC500, to the Department.
Type A
07/30/2025
Section Cited
CCR
87355(e)(2)(3)
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87355(e)(2)(3) Criminal Record Clearance- All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or Request a transfer of a criminal record clearance as specified in Section 87355(c).

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Licensee to ensure compliance with requirements of regulation 87355 regarding criminal record clearances, with facility staff and/or employees of licensed home health agencies. Ensure staff have required criminal record clearance and are associated to the facility as needed per regulation.
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This requirement was not met as evidenced by: Per review of Guardian, criminal record clearance database, S3 is not associated to the facility and was separated by Cogir of Rohnert Park on 12/5/2023. It was also identified that S3's fingerprint clearance was separated from North Bay Home Care agency on 10/9/2024, and separated from North Bay Home Care, INC. agency on 2/18/2025. This is a risk to the' health & safety of all residents'.
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Licensee to submit written plan of future facility compliance regarding 87355 regulation requirements.
POC due 7/30/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4