496803812-7-6-2023-21-AS-HDBI-CTS4VZ-20230715192710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803812
Report Date: 06/20/2023
Date Signed: 07/06/2023 12:07:24 PM

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
06/01/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230601093710

FACILITY NAME:	COGIR OF SONOMA		FACILITY NUMBER:	496803812
ADMINISTRATOR:	MATTHEW HORSTMANN		FACILITY TYPE:	740
ADDRESS:	800 OREGON ST		TELEPHONE:	(707) 996-7101
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	45	CENSUS: 26	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Interim Administrator, Omar Mendoza		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not provide proper medication assistance to resident in care
Resident in care had access to centrally stored medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cogir of Sonoma for the purpose of reinterviewing Resident #1 and delivering complaint findings. LPA was greeted at the door by Interim Administrator, Omar Mendoza, and was granted access into the facility.

During the course of the investigation, LPA Sarangi reviewed resident(s) records, facility records, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses.

Complaint alleges that staff did not provide proper medication assistance to resident in care. Based on interviews that were conducted throughout the investigation, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation. In addition, LPA reviewed resident records and conducted additional interviews which also could not corroborate the allegation. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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

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
06/01/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230601093710

FACILITY NAME:	COGIR OF SONOMA		FACILITY NUMBER:	496803812
ADMINISTRATOR:	MATTHEW HORSTMANN		FACILITY TYPE:	740
ADDRESS:	800 OREGON ST		TELEPHONE:	(707) 996-7101
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	45	CENSUS: 26	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Interim Administrator, Omar Mendoza		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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9

Staff did not properly maintain resident records

INVESTIGATION FINDINGS:

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"AMENDED" This is an amended version of the original report created on June 20, 2023-SEE BELOW.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cogir of Sonoma for the purpose of reinterviewing Resident #1 and delivering complaint findings. LPA was greeted at the door by Interim Administrator, Omar Mendoza, and was granted access into the facility.

During the course of the investigation, LPA Sarangi reviewed resident(s) records, facility records, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses.

** Amended** Complaint alleges that Staff did not properly maintain resident records. Based on interviews and observations that were conducted with staff during the opening of the (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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 5

Control Number 21-AS-20230601093710

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 SONOMA	FACILITY NUMBER: 496803812
	VISIT DATE: 06/20/2023

NARRATIVE

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"AMENDED" This is an amended version of the original report created on June 20, 2023-SEE BELOW.

complaint on June 2, 2023, LPA observed that 2 out of 3 resident records were not complete and had a missing LIC 602 and Resident Reappraisals paperwork from their respective records (See LIC 9099D). Furthermore, LPA observed that Resident #1 did not get Reappraised in the year of 2022 (See LIC 809-Case Mangement-Other dated for July 6, 2023).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Interim Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20230601093710

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 SONOMA	FACILITY NUMBER: 496803812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/27/2023 Section Cited CCR 87506(b)(10)	1 2 3 4 5 6 7	87506 Resident Records (b) Each resident’s record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.	1 2 3 4 5 6 7	Licensee shall conduct staff training on Resident Records and provide a statement regarding future compliance. In addition, Licensee shall submit a LIC 9098-Self Certification.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observations during the opening of the complaint on June 2, 2023, LPA observed that 2 out of 3 resident records were not completed and were missing an LIC 602 and Reappraisals.	8 9 10 11 12 13 14	Plan of Correction due date by June 27, 2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 21-AS-20230601093710

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 SONOMA	FACILITY NUMBER: 496803812
	VISIT DATE: 06/20/2023

NARRATIVE

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Complaint alleges that resident in care had access to centrally stored medications. Based on interviews that were conducted throughout the investigation, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation. LPA conducted additional interviews residents and witnesses which could not corroborate the allegation. LPA toured the facility on June 2, 2023 which included the Medication Room where Centrally Stored Medications are located and observed the Medication Room to be locked and secured. In addition, on said date, LPA toured Resident #1's room and observed no medication accessible to the resident in care.

A finding that the complaint allegation of Staff did not provide proper medication assistance to resident in care and Resident in care had access to centrally stored medications are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Interim Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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