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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701180
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:34:15 PM


Document Has Been Signed on 02/22/2024 03:34 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:COGIR OF TURLOCKFACILITY NUMBER:
502701180
ADMINISTRATOR:JOHNS, JANETFACILITY TYPE:
740
ADDRESS:3791 CROWELL ROADTELEPHONE:
(209) 664-9500
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:100CENSUS: 89DATE:
02/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Anneka Ogundipe, Health and Wellness DirectorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Cambell conducted an unannounced Case Management visit on this date and met with Administrator Tony Montellano and Health and Wellness Director Anneka Ogundipe. Upon entry, LPA Campbell was greeted by the facility receptionist and observed staff cleaning the entry and dining room. Over the course of the visit, LPA Campbell observed residents eating meals, socializing with other residents, and receiving staff assistance entering or exiting the dining room. Residents were observed eating peas and carrots, Sheppards Pie, Broccoli soup and rolls with iced tea or water. Staff were later seen clearing tables or passing out dessert at resident’s request.

The Department received an incident report (IR) on 02/21/24 regarding a 02/06/24 med error. During the visit, the LPA met with Health and Wellness Director Anneka Ogundipe to conduct a short interview and collect any associated documents. LPA Campbell observed an eMAR with the doctors orders to change the frequency of a prescription as well as the IR for the event dated 02/06/24.

According to the orders, the start date for the medication (02/07/24) occurred after the date of the incident report on 02/06/24 as shown on the IR. The Wellness Director, confirmed that the date entered on the IR was in error. The incident instead occurred on 02/07/24 . Also, the incident report was received on 02/20/24 and was therefore received 6 days past the reporting requirement of 7 days. The MedTech (S2) who had dispensed the medication incorrectly, reported that they were at fault because they had not read the med orders or followed the dispensing procedures to avoid med errors.

Per California Code of Regulations (CCR) – a deficiency is being cited on the attached LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. Exit interview held and copy of report given to Health and Wellness Director Anneka Ogundipe .

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/22/2024 03:34 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: COGIR OF TURLOCK
FACILITY NUMBER: 502701180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2024
Section Cited
CCR
87465(a)(5)

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87465 Incidental Medical and Dental Care. (a)A routine plan ... (5) may assist persons with self-administration as needed. Assistance shall be limited to medications... authorized by the person's physician.
This requirement is not met based on:
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The Health & Wellness Director will conduct an audit of client MARS bi-weekly to be charted on the eMAR & will conduct Medication Pass Training for Med Techs by 03/15/24. A sign in sheet with all participants will be faxed with LPA Campbell's name as the recipient.
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Based on interviews and record reviews, 1 of 2 staff reported that they did not assist persons with self-administration as authorized by a person's physician. This poses an immediate Health, Safety or Personal Rights risk to persons in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
LIC809 (FAS) - (06/04)
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