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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 03/28/2025
Date Signed: 03/28/2025 04:22:04 PM

Document Has Been Signed on 03/28/2025 04:22 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:COGIR OF SONOMA PLAZAFACILITY NUMBER:
496804032
ADMINISTRATOR/
DIRECTOR:		CORNEJO, WENDYFACILITY TYPE:
740
ADDRESS:91 NAPA ROADTELEPHONE:
(707) 939-1500
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 105CENSUS: DATE:
03/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:33 PM
MET WITH:Wendy Cornejo, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
04:36 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management inspection and was greeted by Administrator, Wendy Cornejo.

On 3/17/25 CCL received SOC341 from facility reporting suspected abuse of resident (R1). SOC341 indicates R1 is a resident of the Memory Care unit at facility. SOC341 indicates that on 3/15/25 outside agency caregiver (I1) was assisting R1 to their apartment. R1 was resistant to entering their room, so I1 grabbed R1 by the wrist and pulled R1 into their apartment. R1 was pulled such that they lost their footing/balance and hit their head on the closet door knob as well as their left shoulder as they fell to the floor. I1 did not call for help and did not assist R1 up from the floor. I1 then proceeded to lock the apartment door and move about the apartment shutting blinds and adjusting the bedding. R1 remained on the floor until Cogir caregiver (S1) entered the room. S1 immediately performed injury assessment and wellness check on resident. After no injuries were assessed, S1 then helped R1 up with the assistance of I1.

Written statement of S1's account of the incident was submitted to CCL at time of SOC341 submission. S1 states that upon entering R1's apartment she found R1 on the floor. S1 asked I1 what happened. I1 reported to S1 that R1 had become tired and needed to sit down, so I1 pulled the ottoman over for R1 to sit on, but R1 "kind of rolled off" the ottoman, which is why R1 was now on the floor. S1 then assisted R1 up off the floor and proceeded to help R1 with toileting needs before helping R1 in bed to rest.

During visit, LPA interviewed Health and Wellness Director (HWD), Alexandra (Alyx) Fischer. LPA viewed

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COGIR OF SONOMA PLAZA
FACILITY NUMBER: 496804032
VISIT DATE: 03/28/2025
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video record evidence of incident. LPA requested video record be submitted to CCL. Record release requires CDSS written request to be submitted by Licensing Program Manager (LPM). LPA will submit LPM written request to facility once obtained. LPA asked HWD if S1 would be willing to sign and date their written statement that was submitted with SOC341. S1 was not present at facility during LPA visit so HWD will ask S1 and forward to CCL if S1 agrees to sign and date their statement. LPA requested HWD complete a LIC855 Declaration, documenting her accounting of Cogir response to incident and any applicable or additional information has about the incident and I1. HWD will check with corporate Cogir contact as to corporate policy around providing LIC855 Declaration to CCL. HWD will submit LIC855 if/when corporate gives their approval.

Exit interview conducted with HWD and a copy of this report given. No deficiencies cited.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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