216804000-3-28-2025-21-AS-VBEI-DFEVQZ-20250404163906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 03/28/2025
Date Signed: 03/28/2025 02:47:53 PM

Unsubstantiated

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
11/08/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20241108085658

FACILITY NAME:	COGIR OF SAN RAFAEL		FACILITY NUMBER:	216804000
ADMINISTRATOR:	CLAREY, KAITLYN		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(707) 334-1620
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70	CENSUS: 50	DATE:	03/28/2025
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Executive Director, Kimberly Humphrey and Business Office Manager, Ditter Vazquez		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not assist resident with self-administration of medication
Personal Rights

INVESTIGATION FINDINGS:

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At approximately 1:50PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for this Complaint Investigation regarding the above allegations and met with Executive Director, Kimberly Humphrey and Business Office Manager, Ditter Vazquez.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff did not assist in self-administration of medication, and Personal Rights.”

“Staff did not assist in self-administration of medication” – Complainant alleged that facility staff refused to administer Resident 1 (R1’s) morphine medication when they were in extreme pain on 11/03/2025 and 11/04/2025. Complainant also alleged that facility staff forced R1 to take their morphine when they were dying even though R1’s family asked facility staff to not administer it.
Continued on LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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 3

Control Number 21-AS-20241108085658

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 SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 03/28/2025

NARRATIVE

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Continued from LIC9099

Review of R1’s medication records and narcotic log indicated that facility staff were administering R1’s morphine per physician and hospice orders. Review of R1’s routine medications showed that R1 had a prescription for a morphine oral tablet. The morphine oral tablet instructions stated: “Morphine Sulfate Oral Tablet 15MG – Take ½ tablet (7.5MG) by mouth every 4 hours as needed for pain/shortness of breath.”

Record Review for 11/03/2025 showed the following:

· Review of R1’s Narcotic Log shows that R1 was administered morphine at the following times: 5AM, 9:43AM, 11:48AM, 12:10PM, 1:10PM, 4:22PM, 5:43PM,7PM, 9:18PM and 11:25PM.
· R1’s Progress Notes for 11/03/2024 showed that facility staff were communicating with R1’s hospice agency about R1’s increase in pain and were following their instructions. Notes also indicated that Hospice visited R1 on 11/03/2024 to assess them and administer PRN (as needed) morphine.
· At 6:47PM, facility received physician order for “Morphine 15MG oral tablet – Take 1 tablet(s) oral every hour as needed for severe pain; OK to dissolve in water then administer.”

Facility documentation showed that the Facility received this verbal order in the evening after the facility had been giving morphine per hospice instructions.

Hospice Record Review for 11/03/2025 showed that the Hospice Agency conducted visits with R1 at the following times:
· 12PM-2PM; Hospice Notes indicated that R1 was transitioning and that R1 was administered medication
· 5:22PM-8:39PM; Hospice Notes indicated that R1 was administered medication around 3-4PM. Hospice observed R1 to be visibly calm.

Record Review for 11/04/2025 showed the following:

· Review of R1’s Narcotic Log shows that resident was administered morphine at the following times: 9:18AM, 1:57PM, 3:54PM, 5:30PM, 7PM, 8PM, and 9PM
· R1’s Progress Notes showed that R1 was observed to be calm and comfortable at 12:34PM, 2:44PM, 6:55PM, and 6:57PM by facility staff
· At 11:42AM, the facility received verbal orders for the following morphine prescription: 11/4/24; oral concentrate morphine (20MG/ML) administer 0.75ML oral every hour.

Facility documentation indicated that after facility received the new morphine order, they began to administer the new medication order at 3:54PM.

Continued on LIC9099C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20241108085658

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 SAN RAFAEL	FACILITY NUMBER: 216804000
	VISIT DATE: 03/28/2025

NARRATIVE

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Continued from LIC9099C

Hospice Record Review for 11/04/2025 showed that the Hospice Agency conducted visits with R1 at the following times:
· 11:45AM – 12:30PM; Hospice Notes indicated that R1 was observed to be safe and comfortable
· 5:30PM to 6:03PM; Hospice Notes indicated that facility staff administered morphine 15 minutes prior to Hospice’s arrival
· 9:45PM-10:45PM; Hospice Notes indicated that R1 passed and a narcotic medication count was conducted.

“Personal Rights” – Complainant alleged that facility staff argued and verbally harassed R1’s family while R1 was dying. Report received stated that Staff Member 1 (S1) accused R1’s family of physically grabbing and shaking them. Report received stated that Facility’s Executive Director confronted R1’s family about the alleged altercation in front of R1 and did not provide R1 dignity.

Interviews conducted with involved parties revealed conflicting statements. Interview conducted with S1 stated that R1’s family grabbed them to make them administer more morphine to R1 even though R1 didn’t look like they were in pain. Interview conducted with Executive Director stated that they were unable to determine if the altercation happened as S1 and the family were the only ones involved. Interview conducted with Witness 1 (W1) denied that the physical altercation occurred, and that the accusation was false. W1 stated that there was a verbal conversation that occurred between themselves, the Facility Executive Director, and S1, but asserted that there had been no physical contact between them and S1 prior to the verbal exchange. Interview conducted with Witness 2 and Witness 3 (W2 and W3), corroborated W1’s statements that there was no physical altercation between W1 and S1 and that there was no yelling or raised voices during the conversation between the family, the Facility’s Executive Director, and facility staff in front of R1.

Based on interviews conducted, document review, and observations made, these allegations are Unsubstantiated.

A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC9099 (FAS) - (06/04)

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