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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803812
Report Date: 01/26/2024
Date Signed: 01/26/2024 04:31:12 PM


Document Has Been Signed on 01/26/2024 04:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 SONOMAFACILITY NUMBER:
496803812
ADMINISTRATOR:RAFAEL MENDOZAFACILITY TYPE:
740
ADDRESS:800 OREGON STTELEPHONE:
(707) 996-7101
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:82CENSUS: 23DATE:
01/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Rafael Mendoza, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to continue the required Annual inspection and was greeted by Rafael (Omar) Mendoza, Administrator. Facility currently has three [3] residents on hospice which is allowable per the facility's Hospice Waiver. Hospice plans for all three [3] residents were available, LPA reviewed all three [3] plans.

At approximately 9:30am LPA conducted a review of five [5] staff files. LPA observed that staff (S1) did not have a clear TB or chest xray present in file. Additionally S1's Health Screen is dated more than 6 months prior to employment. S1 employed in 2020, Health Screen dated 2018. S2, S3, and S4 had indication that TB skin test was performed but no results in file and chest xray not present. Per Title 22 regulation 87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure (deficiency cited, see 809D).

At approximately 12:15pm LPA, Med Tech (MT) and Health and Wellness Director (HWD) conducted a spot check of medication and medication records. Medication is centrally stored in a locked medication room on the first floor and in med carts stored in the med room. The room contains a refrigerator for refrigerated medications. Narcotics are double locked in the medication carts. Facility currently manages resident medications using EMARs and PCC system. LPA and HWD accompanied MT during afternoon med pass. LPA observed that medications are live poured and med cart remains in control of MT while MT is administering medications to residents. Per LPA, MT, and HWD observation and record review resident (R1) had incorrect expiration and fill dates entered on CSML for their Levothyroxine and Atorvastation prescriptions; resident (R3) had incorrect expiration date entered on CSML for their Metoprolol prescription.



Continued on 809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 2 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SONOMA
FACILITY NUMBER: 496803812
VISIT DATE: 01/26/2024
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Continued from 809...

Per Title 22 regulation 87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:... (D) The date filled... (deficiency cited, see 809D).

At approximately 2:00pm LPA reviewed five [5] resident files. LPA observed R2 did not have a TB screen or results in their file, chest xray present but does not mention negative TB or evidence (or lack) of TB. LPA verified with Admin R2 does not have TB screen. Per Title 22 regulation 87458 Medical Assessment (b) The medical assessment shall include, but not be limited to:(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility (deficiency cited, see 809).

Rafael (Omar) Mendoza Administrator Certificate 6039775740 expires 6/19/2024. All fees are current as of this time, fee due in February. LPA gave Admin PIN to make online fee payment. LPA and Admin discussed facility's Infection Control Plan. LPA reviewed Infection Control Plan. Per Admin no new updates.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Evidence of Liability Insurance
Current Lease
Transportation Procedures

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/26/2024 04:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SONOMA
FACILITY NUMBER: 496803812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(D)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (D) The date filled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA, Med Tech, and HWD observation and record review, the licensee did not comply with the section cited above, resident (R1) had incorrect expiration and fill dates entered on CSML for their Levothyroxine and Atorvastation prescriptions which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying they have conducted staff training on how to properly keep records of medications on CSML. Facility to submit LIC9098 along with proof of training including; completed hours, staff attendees, course name, and trainer.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 01/26/2024 04:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SONOMA
FACILITY NUMBER: 496803812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above in [4] out of [5] staff files reviewed. (S1) did not have a clear TB or chest xray present in file and Health Screen is dated more than 6 months prior to employment. S2, S3, and S4 had indication that TB skin test was performed but no results in file and chest xray not present. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Facility to submit to CCL a Letter of Explanation (LOE) outling plan/schedule of when facility will have staff screened for TB and that the clear TB screen results and/or chest xray are present in each respective staff member's file. Admin provided LOE outling plan to LPA during exit interview. Admin agrees to have all staff TB screen results submited to CCL no later than February 9, 2024.

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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 01/26/2024 04:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SONOMA
FACILITY NUMBER: 496803812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above, LPA observed R2 did not have a TB screen or results in their file, chest xray present but does not mention negative TB or evidence (or lack) of TB. LPA verified with Admin R2 does not have TB screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Facility to submit LIC9098 certifying they have conducted staff training to ensure all residents have an in-service review of required documents and items, including a current Physican's Report with a clear TB screen and/or chest xray, before admission of residents. Facility to submit LIC9098 along with proof of training including; completed hours, staff attendees, course name, and trainer.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7