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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804032
Report Date: 11/20/2025
Date Signed: 11/20/2025 01:03:15 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
09/19/2025 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20250919160909
FACILITY NAME:COGIR OF SONOMA PLAZAFACILITY NUMBER:
496804032
ADMINISTRATOR:CORNEJO, WENDYFACILITY TYPE:
740
ADDRESS:91 NAPA ROADTELEPHONE:
(707) 939-1500
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:105CENSUS: DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Wendy Cornejo, AdministratorTIME COMPLETED:
01:17 PM
ALLEGATION(S):
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Facility staff did not meet residents care needs
Inadequate Staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegations. LPA met with Administrator Wendy Cornejo.

Complaint alleges facility staff did not meet residents care needs. Complainant states that incontinence needs of residents are not being met, that they are found in the morning soaking wet or covered in feces, indicating they had not been changed overnight. During investigation, LPA interviewed witnesses. Three (3) of four (4) witnesses interviewed indicate that they have witnessed the incontinence needs of residents not being met and finding them as the complainant alleges.

Complainant alleges facility does not have adequate staffing. Complainant states that often facility’s Memory Care (MC) is short staffed on the NOC shift. California Code of regulations, Title 22 does not have

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
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-20250919160909
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 SONOMA PLAZA
FACILITY NUMBER: 496804032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2025
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requremient not met by licensee as evidenced by:
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Facility has addressed incontinence care with NOC shift caregivers. Admin was made aware of residents incontinence issues not being met due to employees inadequate ability to idenitify needs of residents. Admin addressed caregiver inadequacies by immediately terminating their
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Based on LPA interviews witnesses indicate that they have witnessed the incontinence needs of residents not being met, which poses an potential health, safety, and/or personal rights risk to resident in care.
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employment. Admin has filled the open positions resulting from termination and trained new staff on proper incontinence care. Admin is also adding another caregiver to NOC shift so that ideally there are 2 Med Techs and 2 caregivers for the NOC. Deficiency cleared.
Type B
12/04/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requremient not met by licensee as evidenced by:
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Facility was understaffed on the NOC shift. Per Admin, facility was utilizing caregivers from registry in order to fulfill need for caregivers. Admin states facility needed to hire a NOC shift caregiver permanently and while they were conducting interviews and reviewing
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Based on LPA interviews facility did not have adequate staffing to meet residents' needs, which poses an potential health, safety, and/or personal rights risk to resident in care.
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candidates for hire they used registry for temporary staff coverage. Per Admin, as of mid to late October, the facility has hired a full time NOC caregiver. LPA reviewed staff schedule. Deficeincy cleared.
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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250919160909
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 SONOMA PLAZA
FACILITY NUMBER: 496804032
VISIT DATE: 11/20/2025
NARRATIVE
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Continued from 9099...

staffing ratio requirements. However, the facility must be able to meet the needs of residents. So, during investigation LPA reviewed the care plans and medical assessment for all 23 Memory Care residents. Of the 23 residents:

· Ambulation: 6 require extensive assistance, 2 require moderate assistance.

· Transferring: 4 require extensive assistance, 4 require moderate assistance, 2 require a two-person assist. · Bathing: 11 require extensive assistance, 4 require moderate assistance.

· Grooming/Dressing: 8 require extensive experience, 6 require moderate assistance.

· Toileting: 4 require extensive assistance, 8 require moderate assistance

· Wandering/Sundowning behavior: 6 are reported to have this behavior

· Fall risk: 3 are identified as being a high risk, 1 identified as a moderate risk, and 2 identified as low risk

During investigation, LPA conducted interviews with witnesses. Four (4) out of six (6) witnesses report that facility's NOC shift is understaffed. LPA received report that medication was not made available to a resident that needed it during NOC shift because there was not a Med Tech or caregiver on duty that could dispense medication. LPA reviewed Memory Care staff schedule. Review of staff schedule shows that at least one Med Tech and 2 caregivers are scheduled each NOC shift. However, on some days schedule shows only one caregiver and one Med Tech for both Assisted Living (AL) and MC; other days it shows only a Med Tech. Per Admin, this is because the facility is utilizing caregivers from registry. Admin states facility needed to hire a NOC shift caregiver permanently and while they were conducting interviews and reviewing candidates for hire they used registry for temporary staff coverage. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D

Conitued on 9099C(2)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250919160909
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 SONOMA PLAZA
FACILITY NUMBER: 496804032
VISIT DATE: 11/20/2025
NARRATIVE
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Continued from 9099C...

Note* Admin advised LPA during delivery of findings that facility has addressed incontinence care with NOC shift caregivers. Admin was made aware of residents incontinence issues not being met due to employees inadequate ability to identify needs of residents. Upon learning of issue, Admin immediately addressed caregiver inadequacies by terminating their employment. Admin has since filled the open positions resulting from termination and trained new staff on proper incontinence care. LPA verified records confirming as such, Admin is also adding another caregiver to NOC shift so that ideally there are 2 Med Techs and 2 caregivers for the NOC.

Exit interview conducted with Admin and a copy of this report given. Appeal rights given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4