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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804032
Report Date: 09/23/2025
Date Signed: 09/23/2025 03:06:42 PM

Document Has Been Signed on 09/23/2025 03:06 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:
09/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:26 AM
MET WITH:Wendy Cornejo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:19 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a case management visit. LPA met with Administrator Wendy Cornejo.

On 8/29/25 CCL received an Incident Report from facility indicating that on 8/20/25 staff discovered R1 had missed 4 days of prescribed Pravastatin Sodium (deficiency cited, see 809D). Also on 8/20/25 R1 was taken to the emergency room (ER) due to feeling weakness on their right side. R1 was diagnosed with a UTI and was prescribed antibiotics. UTI not caused by medication error. R1 returned to the community 8/22/25.

On 9/15/25 CCL received an Incident Report from facility indicating that on 9/8/25 staff was assisting R2 out of her apartment when R2 lost her balance and fell. R2 subsequently reported having back pian. R2 seen at the hospital where they diagnosed them with a neck fracture. R2 returned to the community the same day. LPA reviewed R2 charting notes. Fall was recorded on Safely You video. LPA reviewed video. LPA observed staff (S1) to place walker out of reach of resident and used it to prop open the door to the apartment. R2 fell to the floor and S1 left resident on floor to go and get help. Administrator reviewed with S1 best practices are to remain with resident and radio/call for assistance as well as how to properly use postural support for ambulation. Resident R2 placed on 72 hr monitoring. R2 was scheduled to have a follow up appointment to assess injury, but had a subsequent fall and returned to the hospital on 9/15/25. LPA reviewed assessment and physician's report for R2. Physicians order on file for walker. Assessment indicates extensive hands on assistance with ambulation and transferring needed (deficiency cited, see 809D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. 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.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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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Document Has Been Signed on 09/23/2025 03:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/23/2025 at 10:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SONOMA PLAZA
FACILITY NUMBER: 496804032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2025
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...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 provide to CCL plan indicating they will conduct an in-service training for all medication technicians on all shifts. Plan to be submitted by plan of correction due date. Training to be conducted no later than 10/8/25.
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This requirement not met by licensee as evidenced by: based on LPA record review, R1 missed 4 days of prescribed pravastatin Sodium, which poses an immediate health, safety, and/or personal rights risk to resident in care.
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Type A
10/08/2025
Section Cited
CCR87411(a)

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87411 Personnel Requirements - General (a)Facility personnel shall at all times be ... competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required
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Facility will conduct Postural Supports training with S1 by plan of correction due date.
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in Section 87608, Postural Supports. This requirement not met by licensee as evidenced by: based on LPA record review, S1 did not properly assist R2 with walker, resulting in fall, 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
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