496804032-7-23-2025-21-AS-CCOO-DJUQUW-20250723122926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 07/23/2025
Date Signed: 07/23/2025 12:29:36 PM

Document Has Been Signed on 07/23/2025 12:29 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 PLAZA		FACILITY NUMBER:	496804032
ADMINISTRATOR/ DIRECTOR:	CORNEJO, WENDY		FACILITY TYPE:	740
ADDRESS:	91 NAPA ROAD		TELEPHONE:	(707) 939-1500
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY: 105		CENSUS: 85	DATE:	07/23/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:23 AM
MET WITH:	Wendy Cornejo, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Administrator Wendy Cornejo. On 6/20/25 CCL received an Incident report for resident (R1). Incident report indicated that on 6/10/25 facility was made aware by R1's responsible party that R1's previously diagnosed cellulitis was a staphylococus aureus infection. Facility advised R1's responsible party that staphylococus aureus infections is a prohibited condition. R1 was then seen at their primary care physician the same day, 6/10/25. They then were evaluated at the Emergency Room (ER). The ER diagnosed R1 with septic bursitis of right elbow with a culture of MSSA. MRSA and MSSA are both types of staphylococus aureus, but MSSA is not antibiotic resistant. R1 was then admitted to the ER for antibiotic therapy. R1 was discharged with a diagnosis of traumatic olecranon bursitis with apparent cellulitis. LPA reviewed discharge papers for R1. Papers also note that cellulitis was resolved while in the hospital and infection resolved as well. Discharge papers dated 6/16/25 state that R1 did not need to be in isolation. R1 returned to the facility on 6/16/25. Care plan was updated, Home Health was ordered to monitor R1's elbow, and R1 continued oral antibiotics for approximately one week. Per Health and Wellness Director (HWD), Alyx Fischer, R1's elbow is now healed. No deficiencies cited. On 6/27/25 CCL received an Incident report for Memory Care resident (R2). On 6/27/25 R2 experienced two [2] falls in their room, one at 3:36am and one at 10:58pm. Falls captured on Safely you video and alerted staff. R2 was assessed by staff S1 and S2, no injuries observed by staff or reported by R2. After fall #1, R2 was assisted back into bed and S1 placed R2's wheelchair and their recliner next to R2's bed. After fall #2, R2 was helped back into bed by staff S3 and S1. Once again, S1 placed R2's wheelchair next to her bed. Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

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: 07/23/2025

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Continued from 809...

Upon learning of the incident, HWD observed and interviewed R2, they did not recall having their furniture moved to prevent them from falling out of bed. Memory Care Director (MCD) notified R2's Power of Attorney (POA). All involved team members were placed on suspension pending an internal investigation. HWD reported to Sonoma Sheriff's office (event ID# SO251780006) and MCD, HWD, and Admin all interviewed S1, S2, and S3. S1 reported that they were trying to use the wheelchair and recliner as a fall prevention measure, they did not know it would be or could be considered a form of restraint. Investigation concluded approximately on 7/2/25 and S1 returned to work 7/1/25. S2 and S3 returned to work on 7/2/25. To address the issue of restraints and personal rights, facility conducted in-service training starting on 7/1/25 and concluding on 7/14/25, for all direct care staff. Training topics covered were restraints, personal rights, and mandated reporting. S1, S2, and S3 all participated in the in-service training. No deficiencies cited.

On 7/22/25, Admin notified LPA of theft in facility. Minor instances of theft were previously reported to LPA earlier in the year, suspect unknown. On 7/21/25 at approximately 7:30pm, staff (S4) was caught on camera digging through a recently deceased resident's (R3) belongings. S4 was observed opening a drawer and pulling out an envelope of money. Money was stolen and put in S4's pocket. On 7/22/25 at approximately 10:00am, Admin and HWD contacted Sonoma Sheriff Department (event #SON-250000229 and SON-250000383). Deputy arrived at facility to take report and view video footage of theft. R3's responsible party was notified. At approximately 2:30pm on 7/22/25, S4 was arrested by deputy. Facility immediately terminated S4 as they were being arrested. Case is still being investigated. S4's private residence was searched and additional items of theft from residents of the facility were recovered. Police report pending. Admin will forward S4's information to CCL by 7/28/25. Video footage given to LPA. No deficiencies cited.

Exit interview conducted with Admin and a copy of this report given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

LIC809 (FAS) - (06/04)

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