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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 06/05/2025
Date Signed: 06/05/2025 02:44:31 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
04/01/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250401143349
FACILITY NAME:COGIR OF SAN RAFAELFACILITY NUMBER:
216804000
ADMINISTRATOR:HUMPHREY,KIMBERLYFACILITY TYPE:
740
ADDRESS:111 MERRYDALE ROADTELEPHONE:
(707) 334-1620
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: 53DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Business Office Director, Ditter VasquezTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff handled resident roughly causing resident to fall
Facility did not seek timely medical
Facility did not report abuse to responsible party
INVESTIGATION FINDINGS:
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At approximately 11:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Business Office Director, Ditter Vasquez.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There are allegations that "Staff handled resident roughly causing resident to fall, Facility did not seek timely medical, and Facility did not report abuse to responsible party." Complainant alleged the following: Staff Member 1 (S1) roughly handled Resident 1 (R1) while providing care causing R1 to fall and hit their head, facility did not seek timely medical for R1 after the fall, and facility did not report abuse to R1's responsible party.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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 5
Control Number 21-AS-20250401143349
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: 06/05/2025
NARRATIVE
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Continued from LIC9099

"Staff handled resident roughly causing resident to fall" - Community Care Licensing received an Incident Report and SOC341 Report on 02/25/2025. Reports stated that 02/21/2025, facility received a notice from their fall-detection camera system. Reports stated that in the video footage, Staff Member 1 (S1) was seen grabbing R1, was trying to clean them after they used the bathroom, and that R1 was resistant to receiving the care. Reports further stated that R1 was seen falling backward hitting their head against their bedroom furniture, that S1 did not report the fall to Facility Medication Technicians or the Health and Wellness Director (HWD) on duty, and that Staff Member 2 and Staff Member 3 (S2 and S3) conducted a visual assessment of R1.

LPA reviewed the facility video footage from 02/21/2025. LPA observed that R1 was shown to fall backward with force and significantly hit their head on their nightstand while S1 was providing care.

"Facility did not seek timely medical" - Review of R1’s physician orders indicated that R1 was on a blood thinner medication/anticoagulant. Interviews conducted with S2 and S3 confirmed that they reviewed the video footage on 02/21/2025 and conducted a visual assessment of R1. Interviews revealed that S2 and S3 did not send R1 to the hospital for evaluation per facility protocol because they were instructed by the HWD to not send R1 to the hospital unless they exhibited a change in condition. Per interview with Executive Director, facility protocol is to call emergency services when a resident hits their head. Review of facility’s fall policy stated the following: “…Associates will call Emergency Medical Services (911) when: (a) the resident has…received obvious head or significant trauma, (b) if the resident is on anticoagulants and there is a question of head trauma.”


"Facility did not report abuse to responsible party" - Review of SOC-341 report showed that R1's incident occurred on 02/21/2025 and that the report was received by Community Care Licensing (CCL) on 02/25/2025. Welfare and Institutions Code section 15630(b)(1) states the following: "Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse...shall report the known or suspected instance of abuse...within two working days." Interviews conducted with S2 and S3 confirmed that they viewed the video of R1 and S1 on 02/21/2025 and did not report the suspected abuse incident timely per mandated reporting requirements.

Continued on LIC9099C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20250401143349
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: 06/05/2025
NARRATIVE
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Continued from LIC9099C

Based on record review, interviews conducted, and observations made, these allegations are Substantiated.
A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Business Office Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20250401143349
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities:(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee to submit self-certification that all care staff will receive training on the personal rights of residents by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.
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based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure R1's personal rights. R1 was shown to be handled roughly by S1 while being provided incontinence care. This is an immediate health and safety risk to residents in care.
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Type A
06/06/2025
Section Cited
CCR
87208(a)
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87208 Plan of Operation:(a)The licensee shall have and maintain a current, written definitive plan of operation...The licensee shall operate the facility in accordance with the terms specified... pursuant to Health and Safety Code…This requirement was not met
as evidenced by: Based on record review,
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Licensee to submit self-certification that all care staff will receive training on facility fall protocol by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.
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interviews conducted, and observations made, Licensee did not comply with section cited above. Licensee did not ensure that facility staff followed protocol and ensure that R1 was evaluated timely after hitting their head from a fall. This is an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250401143349
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2025
Section Cited
HSC
15630(b)(1)(A)(i)
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Welfare and Institutions Code: 15630(b)(1)(A)(i): "Any mandated reporter who...has knowledge of an incident...shall report...within two working days (A)If the suspected... abuse occurred in a long-term care facility...(i)...report shall be made within two hours of the mandated reporter...obtaining knowledge
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Licensee to submit self-certification that all care staff will receive training on Reporting Requirements by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.
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of...physical abuse." Requirement not met as evidenced by: based on interviews, record review, and observations, Licensee did not comply with section cited above and did not ensure that R1's suspected abuse was reported timely. This is an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5