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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804000
Report Date: 12/18/2025
Date Signed: 12/18/2025 03:09:36 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
08/25/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250825160019
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:
12/18/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Business Office Director, Ditter Vazquez, Resident Care Coordinator, Mariana Ramirez, and Executive Director, Kimberly HumphreyTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff do not respond to resident's call for assistance
INVESTIGATION FINDINGS:
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At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegation and met with Maintenance Director, Guy Webber. Business Office Director, Ditter Vazquez, arrived during visit at approximately 9:40AM and Executive Director, Kimberly Humphrey, arrived during visit at approximately 11:20AM.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegation, “Staff do not respond to resident's call for assistance.” Complaint alleged that that on 08/24/2025, Resident 1's (R1) emergency cord was pulled but was not responded to. Complaint alleged that facility staff didn’t respond to R1's emergency cord because they weren't wearing their pagers to receive notifications. Additional information provided also alleged that R1's emergency pull cord was pulled and not responded to on 09/24/2025.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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
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
08/25/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250825160019

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:
12/18/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Business Office Director, Ditter Vazquez, Resident Care Coordinator, Mariana Ramirez, and Executive Director, Kimberly HumphreyTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff do not ensure that facility is in good repair
Staff do not have first aid training
INVESTIGATION FINDINGS:
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At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegations and met with Maintenance Director, Guy Webber. Business Office Director, Ditter Vazquez, arrived during visit at approximately 9:40AM and Executive Director, Kimberly Humphrey, arrived during visit at approximately 11:20AM.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegation, “staff do not have first aid training." Complaint alleged that the facility care staff didn’t provide any first aid such as ice packs or Neosporin for R1, after they had a fall on 08/23/2025 and sustained a swollen lip, bleeding nose, and swollen leg.

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

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250825160019
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: 12/18/2025
NARRATIVE
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Continued from LIC9099A

Review of facility schedule for 08/23/2025 showed that there were 8 direct care staff on-site during the evening shift. Review of staff records indicated that 8 of 8 facility staff members had first aid training certificates on file. This allegation is Unsubstantiated.

The Department investigated the following allegation, “staff do not ensure that facility is in good repair.” Complaint alleged that facility’s camera system was not working. Complaint alleged that facility staff were aware that the system was down on the morning of 08/23/2025 but did not communicate it to residents or their responsible parties. Facility partners with a third-party vendor, Safely You, that has cameras throughout the building to notify the facility staff of a potential fall. Interview conducted with Executive Director stated that Safely You Technicians were on-site for 3 to 4 days to resolve the camera issue. Facility documents also indicated that on 08/29/2025, the Safely You cameras were online and active. The camera system is maintained and managed by Safely You. Therefore, it is the third-party vendor’s responsibility to ensure that their system is functioning appropriately and not the facility’s. This allegation is Unsubstantiated.

A finding that a 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.

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

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20250825160019
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: 12/18/2025
NARRATIVE
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Continued from LIC9099

Review of R1’s call pendant records for August 2025 indicated that on 08/24/2025, R1’s pendant was pulled at 8:11AM and was not received or responded to as of 8:56AM. Review of R1’s call pendant records for September 2025 indicated that on 09/24/2025, R1’s pendant was pulled at 9:45AM and was not received or responded to as of 10:30AM. Additional review of R1's pendant call records also showed that on 09/25/2025, R1’s pendant was pulled at 6:06PM and was not received or responded to as of 6:51PM.

Per interview with Health and Wellness Director, it was identified that some facility staff were not wearing or using their pagers as required. Health and Wellness Director also stated that they identified that the facility also had a low supply of employee pagers. Review of facility documents showed that an Standard Operating Procedure (SOP) document titled, "Use of Pagers for Responding to Pull Cord Alerts," was signed by facility staff on 08/30/2025.

Based on record review, interviews, and observations made, this allegation is 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, Plan of Corrections, and Appeal Rights, 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: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250825160019
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: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to...Section 87468.1... residents...shall have...following personal rights: (4) To care, supervision, and services that meet their...needs and are delivered by staff that are sufficient in numbers,
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Licensee to submit self-certification that training will be conducted for all care staff reviewing equipment expectations by POC due date of 12/29/2025. In-service training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures.
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qualifications & competency...Requirement was not met as evidenced by: based on record review & interviews, Licensee did not comply with section cited above & did not ensure that R1's pendant call was responded to timely. This poses a potential health/safety risk to residents in care.
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In-service training to be submitted to CCL by POC due date of 01/09/2025.
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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: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5