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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804000
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:13:51 PM

Document Has Been Signed on 02/14/2024 03:13 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:COGIR OF SAN RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR:SUSAN EDWARDSFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(415) 472-6530
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 70CENSUS: 49DATE:
02/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Executive Director/Administrator, Susan EdwardsTIME COMPLETED:
01:00 PM
NARRATIVE
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At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Annual Continuation visit and met with Executive Director/Administrator, Susan Edwards. Upon arrival, LPA was informed that there were 49 Residents in care and 26 staff members on-site.

At approximately 10:00AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed 6 resident files and 4 resident medication records. Resident files were all found to be well organized, thorough and contained the required documentation. Medication was found to be centrally stored and secure.

LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received a incident report on 02/12/2024. Report stated that on 02/09/2024, Resident 1 (R1) was found by facility staff at the end of the facility's driveway. Report stated that the facility's front door has delay egress and was alarmed. Facility made all appropriate notifications per regulation. (This deficiency has been cited, see LIC809D, Regulation 87705(b)(2).

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 03/14/2024.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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 02/14/2024 03:13 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 02/14/2024 at 12:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SAN RAFAEL
FACILITY NUMBER: 216804000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(b)(2)
87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility and at the end of the facility’s driveway. R1’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee to submit self-certification stating that an in-service training will be conducted with all care staff regarding Elopement Procedures by POC due date of 02/15/2024. In-service training to include the following: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 02/25/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SAN RAFAEL
FACILITY NUMBER: 216804000
VISIT DATE: 02/14/2024
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Continued from LIC809

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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