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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804032
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:29:57 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
11/06/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241106151738
FACILITY NAME:COGIR ON NAPA ROADFACILITY NUMBER:
496804032
ADMINISTRATOR:CORNEJO, WENDYFACILITY TYPE:
740
ADDRESS:91 NAPA ROADTELEPHONE:
(707) 939-1500
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:105CENSUS: 75DATE:
11/15/2024
UNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Wendy Cornejo, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility administered the incorrect medication to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Coppo met with Administrator Wendy Cornejo to investigate a complaint regarding the allegation of “facility administered the incorrect medication to resident in care."

Complaint alleges a medication technician at facility administered another resident’s medication to resident listed as R1. R1 was taken to the emergency room to be evaluated and returned to the community the same day. Based on interviews and a record review, R1’s responsible party received a call from the facility on October 13, 2024 alerting them of a medication error and that R1 was taken to the ER out of precaution. R1 was discharged back to the community the same day. Additionally, on October 17, 2024 the Department received an Special Incident Report (SIR) from the facility, related to the medication error and steps taken to ensure R1’s safety.


Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
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-20241106151738
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 ON NAPA ROAD
FACILITY NUMBER: 496804032
VISIT DATE: 11/15/2024
NARRATIVE
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Continued from 9099C...

SIR also included that phone calls to R1’s responsible party were done to make them aware of the medication error. Based on the above, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241106151738
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 ON NAPA ROAD
FACILITY NUMBER: 496804032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.
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Facility to conduct an in-service training for all medication technicians on all shifts. Facility to provide to CCL a written plan to ensure all medication technicians are trained before the END of the November 2024. Copies of training material and roster of staff trained must be maintained on file for CCL review.
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This requirement was not met by licensee as evidenced by: R1 received another resident’s medication, which poses an immediate health, safety, and/or personal rights risk to resident 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: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3