496804032-1-26-2023-21-AS-CMAZ-CNGVLW-20230127153236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804032
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:33:06 AM

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
01/04/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230104155631

FACILITY NAME:	COGIR ON NAPA ROAD		FACILITY NUMBER:	496804032
ADMINISTRATOR:	CORNEJO, WENDY		FACILITY TYPE:	740
ADDRESS:	91 NAPA ROAD		TELEPHONE:	(707) 939-1500
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	105	CENSUS: 73	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Business Officer Manager, Kim Fowlkes Administrator, Wendy Cornejo		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff engaged in an illegal activity while on the facility grounds

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of delivering complaint findings. LPA was greeted at the door by, Business Officer Manager, Kim Fowlkes, and was granted access into the facility. Administrator arrived 30 minutes later.

During the delivery of complaint findings, LPA reviewed a staff members file (See LIC 859), facility incident reports from December 2022 to January 26, 2023, interviewed staff members and residents. In addition, LPA toured the facility with the Administrator on January 26, 2023 and made observations. LPA found the facility to be clean and at a comfortable temperature with all exits free from obstruction.

Complaint alleges that staff engaged in an illegal activity while on the facility grounds. Based off of interviews that were conducted with residents and staff, review of staff records and review of facility records. LPA could not prove or disprove that the facility staff engaged in an illegal activity while on the facility grounds. Furthermore, statements made during the course of the investigation 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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230104155631

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 ON NAPA ROAD	FACILITY NUMBER: 496804032
	VISIT DATE: 01/26/2023

NARRATIVE

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A finding that the complaint allegation of Staff engaged in an illegal activity while on the facility grounds is 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 Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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