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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803807
Report Date: 10/20/2022
Date Signed: 10/20/2022 05:51:25 PM

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
10/14/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221014122049
FACILITY NAME:COGIR OF ROHNERT PARKFACILITY NUMBER:
496803807
ADMINISTRATOR:ACUMABIG, JOSEFACILITY TYPE:
740
ADDRESS:4855 SNYDER LANETELEPHONE:
(707) 585-7878
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:45CENSUS: 25DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jose Acumabig-AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility is not following food service safety practices/procedures with food being served to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/20/22, at approximately 2:50pm, and met with the Administrator Jose Acumabig.

Upon Entry into the facility, the LPA was immediately screened by the front reception desk staff Jeannette. The LPA discussed the complaint allegations with the Administrator and conducted interviews with staff and other parties. The LPA toured the Kitchen and the large resident dining area. The LPA observed food items, salads, pie slices, juice/milk in cups with lids, fruit bowls covered with parchment paper, and wine poured in glasses covered with parchment paper. The hot food is made early and prepackaged in containers ready for when residents pick-up their food andor it is delivered to the resident.

Continued LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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 5
Control Number 21-AS-20221014122049
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 ROHNERT PARK
FACILITY NUMBER: 496803807
VISIT DATE: 10/20/2022
NARRATIVE
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The food items are not kept at the temperature they are required to be at, cold items are not refrigerated or made to be kept cold, and hot items are not in heated conainers to retain the food hot as it is meant to be. LPA discussed General Food Service Requirements with the Administrator, who stated his understanding of the regulation and the concerns stated regarding the food put out for residents meals.

Per the investigation, LPA observed many food items left out on a table for resident pick-up at mealtime; The foods are not retained as required at temperatures for cold food items and/or temperatures for hot food items. This is a health and safety risk to residents in care.

Due to the substantiation of the allegation, "Facility is not following food service safety practices/procedures with food being served to residents", deficiency citation will be issued, 87555 (b)(9)(23)General Food Service Requirements-see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Appeal Rights Given.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20221014122049
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 ROHNERT PARK
FACILITY NUMBER: 496803807
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/21/2022
Section Cited
CCR
87555(b)(9)(23)
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87555 (b)(9)(23)General Food Service Requirements-Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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Licensee to ensure that the facility is following regulations, and that cold food items are kept cold at appropriate temperature, and hot foods are kept at appropriate hot temperature. Licensee to ensure food is also safe for resident consumption, and food is nutritious.
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This requirement has not been met as evidenced by: LPA observed food prepared for residents out on a table in the dining room area for resident pick-up at dinner time; There were salads in plastic containers, drinks/juice/milk in cups w/lids, fruit bowls covered by parchment paper-wine in glasses covered by parchment paper, pie slices , all items not kept at refrigerated temperatures as needed. Hot foods will be prepared and put in containers put out for pick-up but not kept in something to retain heat as needed. Per the Administrator the food was being done earlier and served -put out on table fto have it ready when residents want to pick it up. This is a risk of resident's health & safety and/or a personal rights risk to residents in care.
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Licensee to submit how the food service will be handled regarding residents picking up their meals and/or having their meals delivered where the food is kept healthy and safe to serve to residents in care.Submit policies and procedures on the above by 10/24/22. Plan of correction is due 10/21/22.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/14/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221014122049

FACILITY NAME:COGIR OF ROHNERT PARKFACILITY NUMBER:
496803807
ADMINISTRATOR:ACUMABIG, JOSEFACILITY TYPE:
740
ADDRESS:4855 SNYDER LANETELEPHONE:
(707) 585-7878
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:45CENSUS: DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jose Acumabig-AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility is not preventing the spread of COVID-19 and not following covid infection control procedures
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/20/22, at approximately 2:50pm, and met with the Administrator Jose Acumabig.

Upon Entry into the facility, the LPA was immediately screened by the front reception desk staff Jeannette. The facility has reported covid+ staff as required, and they have isolated/quarantined as needed. Local Public Health(LPH) was notified and directed steps needing to be taken regarding the covid positive staff; Administrator followed the LPH directives. Currently there are no residents and/or other staff with covid at this time in the RCFE, Residential Care For The Elderly, which is the area licensed. Licensing Agency has no jurisdiction over the Independent Living Units on the property. The investigation revealed that the facility at this time is following facility covid practices.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20221014122049
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 ROHNERT PARK
FACILITY NUMBER: 496803807
VISIT DATE: 10/20/2022
NARRATIVE
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There was differing information obtained from reporting party(s) regarding the allegation. Based on LPAs observations, record reviews, interviews with staff, there is insufficient information to prove or disprove the allegation of "Facility is not preventing the spread of COVID-19 and not following covid infection control procedures." Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
No citations/deficiencies.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5