Inspection Reports for Cogir of San Rafael
111 Merrydale Rd, San Rafael, CA 94903, United States, CA, 94903
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. However, some deficiencies were cited over time, primarily related to medication management, resident safety including elopement risks, and communication with residents’ representatives. The facility faced immediate civil penalties twice for medication errors and unsecured medications, including a $1,000 fine in April 2025 and a $250 fine in October 2025. Serious issues included a substantiated sexual assault by a staff member in June 2023, with related failures in timely medical attention and reporting, and repeated concerns about monitoring residents with dementia. The most recent inspection on October 28, 2025, cited a medication administration error that was corrected during the visit, showing ongoing attention to compliance but indicating some persistent challenges.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 52
Capacity: 70
Deficiencies: 1
Oct 28, 2025
Visit Reason
The visit was an unannounced Case Management - Other inspection to conduct the facility's quarterly Non-Compliance inspection and to follow up on a self-submitted incident report regarding medication administration.
Findings
The inspection found that staff hired between July and October 2025 had appropriate training documented. A deficiency was cited for medication being administered to the wrong resident, which posed an immediate health and safety risk. The facility provided proof of corrective training, and the deficiency was cleared during the visit. An immediate civil penalty of $250 was issued for a repeat violation of the same regulation within 12 months.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication was administered to the wrong resident, violating regulation 87465(a)(4). | Type A |
Report Facts
Civil penalty amount: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director | Met with Licensing Program Analyst during inspection and named in relation to findings and exit interview |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection and signed the report |
| Victoria Bertozzi | Licensing Program Manager | Named in report related to licensing program management |
Inspection Report
Census: 52
Capacity: 70
Deficiencies: 1
Sep 3, 2025
Visit Reason
The visit was an unannounced Case Management - Incident Visit to follow up on incident reports submitted to Community Care Licensing regarding residents exiting the facility without assistance.
Findings
The inspection found that the facility did not ensure staff awareness when Resident 2 left the facility without assistance, posing an immediate health and safety risk. A deficiency was cited under Regulation 87705(d) related to monitoring exits for residents at risk of elopement, which was cleared with a Plan of Correction provided during the visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to residents at risk for elopement, resulting in staff not being aware that Resident 2 left the facility without assistance. | Type A |
Report Facts
Capacity: 70
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director | Met with Licensing Program Analyst during inspection |
| Florence Van Heusden | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
| Victoria Bertozzi | Licensing Program Manager | Named in report |
Inspection Report
Census: 54
Capacity: 70
Deficiencies: 0
Jul 31, 2025
Visit Reason
The visit was an unannounced Case Management - Legal/Non-Compliance inspection conducted to review in-service training and compliance with reporting requirements, personal rights, incidental medical and dental care, Welfare and Institutions Code, and administrator responsibilities.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst obtained copies of relevant in-service training and conducted an exit interview with the facility's Executive Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director | Met with Licensing Program Analyst during inspection and named in report. |
| Florence Van Heusden | Health and Wellness Director | Met with Licensing Program Analyst during inspection. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit. |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Capacity: 70
Deficiencies: 0
Jun 20, 2025
Visit Reason
An office meeting was conducted to discuss recent substantiated allegations and to extend the Non-Compliance Plan for the facility.
Findings
No deficiencies were cited during the visit. The facility's Non-Compliance plan was extended for an additional two years with an end date of 06/20/2027, and progress will be reviewed after one year.
Report Facts
Non-Compliance Plan Extension Duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Manager | Present at meeting and named in report |
| Caitlynn Felias | Licensing Program Analyst | Present at meeting and named in report |
| Kimberly Humphrey | Executive Director | Present at meeting and named in report |
| Kristina Munoz | Regional Vice President of Operations | Present at meeting and named in report |
| Phil Altman | Senior Vice President of Operations | Present at meeting and named in report |
| Payam Saljoughian | Partner with HansonBridgett | Present at meeting and named in report |
Inspection Report
Census: 55
Capacity: 70
Deficiencies: 0
Apr 9, 2025
Visit Reason
The visit was an unannounced Case Management - Legal/Non-Compliance inspection conducted to review employee documentation and in-service training compliance.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed employee records and in-service training documentation, and the facility is scheduled for additional training at the end of the month.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and provided documentation. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 70
Deficiencies: 0
Mar 28, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not assist a resident with self-administration of medication and violated personal rights.
Findings
The investigation found that facility staff administered morphine medication per physician and hospice orders and that the allegations of staff refusing medication assistance and verbal harassment were unsubstantiated. Conflicting statements and lack of evidence led to no deficiencies cited.
Complaint Details
The complaint alleged that staff refused to assist Resident 1 with morphine medication during extreme pain and forced medication administration against family wishes. It also alleged verbal harassment and physical altercation involving the resident's family. The investigation found these allegations unsubstantiated due to conflicting statements and lack of evidence.
Report Facts
Medication administration times: 10
Medication administration times: 7
Facility capacity: 70
Resident census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director | Met during investigation and involved in interview regarding personal rights allegation |
| Ditter Vazquez | Business Office Manager | Met during investigation |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 70
Deficiencies: 0
Mar 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-01-27 alleging inadequate food service, unsanitary meal preparation, improper dishwashing, and delayed medical attention for residents.
Findings
The investigation found that the dishwasher was operative and sanitation protocols were followed. Facility menus complied with regulations, and food service satisfaction was reported by family members. Medical records showed timely medical attention for a resident with no evidence supporting the allegations. The complaint was determined to be unsubstantiated with no citations issued.
Complaint Details
The complaint was unsubstantiated based on interviews, document reviews, and observations. No preponderance of evidence was found to prove or disprove the allegations regarding food service and medical attention.
Report Facts
Facility capacity: 70
Resident census: 50
Complaint control number: 21-AS-20250127130724
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Humphrey | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 70
Deficiencies: 1
Mar 14, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the facility's emergency call system was in disrepair, specifically that pull cords were not functional and staff were not receiving calls on their pagers.
Findings
The investigation substantiated the complaint that the facility's emergency call system was malfunctioning. The system was not working approximately four weeks prior but was fully repaired on 03/10/2025. Staff interviews and document reviews confirmed the issues with the pull cords and pagers, and the facility took corrective action by repairing the system and checking all devices for functionality.
Complaint Details
The complaint was substantiated based on interviews and document review. The allegation that the facility's emergency call system was in disrepair was found valid because the preponderance of evidence standard was met.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure that the pull cord system was operating as required, posing a potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 70
Census: 50
Plan of Correction Due Date: Mar 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director/Administrator | Met with Licensing Program Analyst during investigation and provided information about the call system repair |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 70
Deficiencies: 0
Feb 26, 2025
Visit Reason
The visit was conducted as a Case Management - Incident Visit to follow up on an incident report self-submitted to Community Care Licensing regarding a fall incident involving a resident.
Findings
The investigation found that a staff member was observed grabbing a resident who fell backward and hit their head, but the fall was not reported by the staff member. The facility conducted an assessment and made all required notifications. No deficiencies were cited during the visit.
Complaint Details
The complaint involved an incident where Staff Member 1 was seen trying to clean a resident who was resistant, resulting in the resident falling and hitting their head. Staff Member 1 did not report the fall and was suspended pending internal investigation.
Report Facts
Incident report date: Feb 21, 2025
Incident report received date: Feb 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ditter Vasquez | Business Office Director | Met with Licensing Program Analyst during the visit |
| Kimberly Humphrey | Administrator/Director | Facility Administrator/Director named in the report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 70
Deficiencies: 0
Feb 26, 2025
Visit Reason
Unannounced complaint investigation visit regarding an allegation that the facility did not submit a report to the Department about potential abuse related to a medication error.
Findings
The allegation was found to be unfounded based on interviews, document review, and observations. No deficiencies were cited during the visit.
Complaint Details
Allegation of failure to report potential abuse involving a medication error was investigated and found to be unfounded.
Report Facts
Capacity: 70
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
| Ditter Vasquez | Business Office Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 70
Deficiencies: 0
Feb 7, 2025
Visit Reason
The inspection was conducted as a case management follow-up regarding a recent self-reported incident where staff was observed throwing water on a resident.
Findings
The facility is in the process of conducting an internal investigation. Licensing staff obtained documents and spoke with a witness. No deficiencies were cited during this inspection.
Complaint Details
The visit was complaint-related due to a self-reported incident involving staff throwing water on a resident. The facility is investigating internally. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberley Humphrey | Administrator | Met with during inspection and mentioned in relation to the incident investigation. |
Inspection Report
Annual Inspection
Census: 47
Capacity: 70
Deficiencies: 3
Jan 23, 2025
Visit Reason
The inspection was an unannounced annual case management continuation visit to evaluate compliance with licensing requirements and follow up on a Non-Compliance Plan.
Findings
The facility was found to have deficiencies including lack of current First Aid and CPR certifications for most direct care staff, and failure to administer medication as prescribed to a resident. Two incident reports involving medication errors were reviewed, resulting in staff terminations and required in-service training.
Severity Breakdown
Type A: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| 5 of 6 direct care staff members did not have current First Aid certification; 3 of 6 did not have CPR certification. | Type A |
| 1 of 5 residents did not have an updated Physician's Report as required. | — |
| Resident 2 did not receive their medication as prescribed on 01/14/2025. | Type A |
Report Facts
Residents present: 47
Total capacity: 70
Staff members on site: 19
Staff hired: 5
Missing medication tablets: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director | Informed Licensing Program Analysts about staff terminations and facility operations |
| Ditter Vasquez | Business Office Director | Met with Licensing Program Analysts during inspection |
| Remy Fairbairn | Wellness Nurse | Met with Licensing Program Analysts during inspection |
Inspection Report
Annual Inspection
Census: 44
Capacity: 70
Deficiencies: 0
Jan 9, 2025
Visit Reason
Unannounced Required 1 Year Visit to evaluate facility compliance with regulations and care standards.
Findings
Facility was found clean, with appropriate infection control, sufficient supplies, and compliance with safety regulations. No deficiencies were cited during the visit. The annual inspection was not completed and will continue at a later date.
Report Facts
Staff on-site: 22
Hospice waiver capacity: 16
Bedridden resident capacity: 20
Hot water temperature range: 105
Hot water temperature range: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director | Met with Licensing Program Analysts during inspection |
| Angela Ramos | Health and Wellness Nurse | Met with Licensing Program Analysts during inspection |
Inspection Report
Census: 46
Capacity: 70
Deficiencies: 0
Oct 29, 2024
Visit Reason
Unannounced Case Management - Legal/Non-Compliance visit to review employee documentation and update administrator paperwork.
Findings
The facility hired 2 individuals between July and October 2024 and has either conducted or scheduled required training for them. Administrator paperwork was received to update the administrator to Kimberly Humphrey. No deficiencies were cited during the visit.
Report Facts
Number of employees hired: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Humphrey | Executive Director / Administrator | Met during visit and named as new Administrator |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
| Victoria Bertozzi | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 70
Deficiencies: 0
Aug 21, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff were not following doctor's orders for resident's wound care and that the facility was overcharging a resident.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The facility stopped providing discontinued compression devices as ordered, did not deny home health agency access for wound care, and removed disputed charges from the resident's bill. No deficiencies were cited during the visit.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not following doctor's orders for wound care and overcharging a resident. Prior substantiated concerns regarding billing and wound care services were addressed and charges removed. The facility did not deny home health agency access.
Report Facts
Facility capacity: 70
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
| Davina Barker | Regional Executive Director | Met with Licensing Program Analyst during investigation |
| Susan Edwards | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 70
Deficiencies: 2
Aug 8, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that the facility did not provide an updated care plan with explanation of care charges and did not respond timely to the representative.
Findings
The investigation substantiated that the facility failed to provide written notice of rate increases related to wound care services within two business days and did not respond timely to the resident's representative's inquiries, posing potential health and safety risks.
Complaint Details
The complaint was substantiated. Allegations included failure to provide updated care plan with explanation of care charges and failure to respond timely to the representative. Evidence showed verbal notifications were given but no written notice was provided, and communication delays occurred despite multiple contacts by the representative.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide written notice of rate increase due to change in level of care within two business days as required by HSC 1569.657(a). | Type B |
| Failure to ensure communication with resident's representative was answered promptly and appropriately as required by CCR 87468.1(a)(9). | Type B |
Report Facts
Capacity: 70
Census: 44
Deficiencies cited: 2
Plan of Correction Due Date: Aug 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Davina Barker | Regional Executive Director | Met with investigators during the complaint investigation |
| Victoria Mozaffari | Health and Wellness Director | Interviewed during the investigation regarding care plan and wound care services |
Inspection Report
Census: 44
Capacity: 70
Deficiencies: 0
Jul 31, 2024
Visit Reason
The visit was an unannounced Case Management - Other inspection conducted to perform a Non-Compliance (NCC) inspection and review employee documentation for hires between April 2024 and July 2024.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed employee training documentation and was informed of a change in facility administration.
Report Facts
Number of employees hired: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaitlyn Clarey | Administrator | Met during inspection and named as current Administrator |
| Kristina Munoz | Regional VP of Operations | Met during inspection |
| Davina Barker | Regional Executive Director | Met during inspection and will be overseeing the community as the new Administrator |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection |
| Victoria Bertozzi | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 70
Deficiencies: 0
May 2, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that staff did not provide a responsible party with a 30-day eviction notice and that staff did not report an incident to Community Care Licensing (CCL).
Findings
The investigation found the allegation regarding failure to provide a 30-day eviction notice to be unsubstantiated, as the resident was still at the facility and no formal eviction occurred. The allegation that staff did not report an incident to CCL was found to be unfounded, with documentation showing the incident was reported timely. No deficiencies were cited during the visit.
Complaint Details
The complaint investigation involved two allegations: 1) Staff did not provide responsible party with 30-day eviction notice, which was unsubstantiated; 2) Staff did not report incident to CCL, which was unfounded.
Report Facts
Capacity: 70
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Administrator/Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 45
Capacity: 70
Deficiencies: 1
Apr 22, 2024
Visit Reason
The visit was an unannounced Case Management - Legal/Non-compliance inspection conducted to evaluate compliance with regulations related to dementia care and medication management.
Findings
The inspection found that the medication cart was unattended and unlocked with routine and narcotic medications accessible, posing an immediate health and safety risk. A deficiency was cited for this violation, and an immediate civil penalty of $1,000 was assessed for a repeat violation.
Deficiencies (1)
| Description |
|---|
| Medication cart was unattended and unlocked with routine and narcotic medications accessible, posing an immediate health and safety risk to residents. |
Report Facts
Immediate Civil Penalty: 1000
Capacity: 70
Census: 45
Number of employees hired: 2
Hospice waiver capacity: 16
Bedridden resident capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Administrator/Executive Director | Met with Licensing Program Analysts during inspection and named in findings |
| Julie Florio | Licensing Program Analyst | Conducted inspection and signed report |
| Bethany Moellers | Licensing Program Manager | Named as supervisor and Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 49
Capacity: 70
Deficiencies: 1
Feb 14, 2024
Visit Reason
Unannounced Case Management - Annual Continuation visit to evaluate facility compliance and follow up on a recent incident report.
Findings
The facility was found to have compliant staff background checks and well-organized resident files. However, a deficiency was cited due to a resident with dementia eloping from the facility, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident 1 eloped from the facility and was found at the end of the driveway; safety measures for residents with dementia were inadequate. | Type A |
Report Facts
Residents in care: 49
Staff on-site: 26
Capacity: 70
Plan of Correction Due Date: Feb 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director/Administrator | Met with Licensing Program Analyst during inspection |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kimberley Mota | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 70
Deficiencies: 0
Feb 14, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident was issued an unlawful eviction.
Findings
The investigation found that the eviction notices were issued due to nonpayment of fees and complied with Title 22 regulations. The complaint of unlawful eviction was determined to be unfounded, with no deficiencies cited during the visit.
Complaint Details
The complaint alleged an unlawful eviction of a resident. The investigation reviewed eviction notices and related documents, finding that the notices met regulatory requirements and the eviction was due to nonpayment of fees. The complaint was found to be unfounded.
Report Facts
Eviction Notices Issued: 4
Facility Capacity: 70
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director/Administrator | Met with Licensing Program Analyst during complaint investigation. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 49
Capacity: 70
Deficiencies: 1
Jan 29, 2024
Visit Reason
Unannounced Required 1 Year Visit to evaluate compliance with regulations and facility operations.
Findings
The facility was generally found clean, safe, and compliant with infection control and safety regulations. However, a deficiency was cited for storing alcohol accessible to residents with dementia, posing an immediate health and safety risk. The facility is currently on a Non-Compliance Plan and has implemented corrective actions including staff training and updated care plans.
Severity Breakdown
Immediate Civil Penalty: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A bottle of wine was observed to be in Resident 1's room, violating regulation requiring alcohol to be stored inaccessible to residents with dementia. | Immediate Civil Penalty |
Report Facts
Capacity: 70
Census: 49
Direct care staff on-site: 9
Immediate Civil Penalty amount: 250
Plan of Correction due date: Jan 30, 2024
Plan of Correction training sign-in sheet due date: Feb 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Administrator/Executive Director | Met with Licensing Program Analyst during inspection and involved in facility operations |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kimberley Mota | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 53
Capacity: 70
Deficiencies: 0
Oct 27, 2023
Visit Reason
The visit was an unannounced Case Management - Other visit to conduct a Non-Compliance (NCC) inspection and to follow up on self-reported incidents submitted to Community Care Licensing (CCL).
Findings
The facility serves residents with dementia and has an approved fire clearance and hospice waiver. Five employees hired between July and October 2023 have received or are scheduled for required training. The facility is undergoing scheduled renovations with safety measures in place. Multiple self-reported incidents involving resident altercations and staff communication concerns were reviewed and addressed with appropriate notifications and training. No deficiencies were cited during the visit.
Report Facts
Employees hired: 5
Residents bedridden capacity: 20
Hospice waiver capacity: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Administrator/Executive Director | Met with Licensing Program Analyst during visit and involved in incident investigations and facility operations |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit and follow-up on incidents |
| Kimberley Mota | Licensing Program Manager | Named in report header and signature sections |
Inspection Report
Census: 50
Capacity: 70
Deficiencies: 0
Jul 17, 2023
Visit Reason
The purpose of the office meeting was to hold a Non-Compliance (NCC) meeting to address areas of concern identified by the Department.
Findings
No deficiencies were cited during the Non-Compliance Conference. The issuance of a Civil Penalty is under review related to a violation potentially constituting physical abuse or serious bodily injury to a resident.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director/Administrator | Met with during the office meeting |
| Kimberley Mota | Licensing Program Manager | Present at the meeting and named in the report |
| Caitlynn Felias | Licensing Program Analyst | Present at the meeting and named in the report |
| Benoit Levesque | Executive Vice President of Operations | Present at the meeting |
| Holly McMurray | Executive Vice President of Care and Compliance | Present at the meeting |
| Joel Goldman | Partner with HansonBridgett | Present at the meeting |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 70
Deficiencies: 1
Jul 14, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations including staff storing items in a resident's refrigerator, failure to seek timely medical attention for a resident, failure to observe changes in a resident's condition, and failure to respond to a resident's call cord.
Findings
The investigation substantiated the allegation that staff stored an opened alcoholic beverage in a resident's room, posing a health and safety risk. The other allegations related to medical attention, observation of condition changes, and call cord response were found to be unsubstantiated based on documentation and interviews.
Complaint Details
The complaint investigation was substantiated for the allegation of staff storing items in a resident's refrigerator (specifically an opened alcoholic beverage). The other allegations regarding timely medical attention, observation of condition changes, and call cord response were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| An opened alcoholic beverage was observed in Resident 1's room, violating storage requirements for residents with dementia and posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 70
Census: 50
Plan of Correction Due Date: Jul 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director/Administrator | Met with Licensing Program Analyst during investigation |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 52
Capacity: 70
Deficiencies: 4
Jun 30, 2023
Visit Reason
The visit was an unannounced Case Management - Other visit to follow up on self-reported incidents submitted to Community Care Licensing, review the plan of corrections submitted, and to schedule a Non-Compliance Conference.
Findings
Two incidents involving residents were reported and reviewed, with appropriate staff intervention and notifications made. The facility increased staff supervision and conducted in-service training on resident care plans and safety. Previously cited deficiencies from a complaint investigation and case management visit were cleared during this visit. No deficiencies were cited during this visit.
Complaint Details
The visit included follow-up on a complaint investigation dated 09/12/2022. Deficiencies cited during that investigation were cleared during this visit.
Deficiencies (4)
| Description |
|---|
| Personal Rights 87468(a) |
| Incidental Medical and Dental Care 87465(g) |
| Welfare and Institutions Code Section 15630(b)(1)(A)(i) |
| Administrator - Qualifications and Duties 87405(a) |
Report Facts
Capacity: 70
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Administrator/Executive Director | Met with Licensing Program Analyst during the visit and discussed incidents and plan of corrections |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
| Kimberley Mota | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 70
Deficiencies: 3
Jun 2, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including personal rights violation (sexual assault), neglect/lack of supervision, and failure to report incidents timely.
Findings
The investigation substantiated that a resident was sexually assaulted by a staff member, the facility failed to seek timely medical attention for the resident, and the facility did not report the incident within mandated timeframes. The staff member was arrested based on DNA evidence. Deficiencies related to personal rights and reporting requirements were cited.
Complaint Details
The complaint involved allegations that a resident was sexually assaulted by a staff member, the facility failed to provide timely medical attention, and failed to report the incident timely. The allegations were substantiated based on investigation findings including DNA evidence and delayed reporting.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Personal Rights of residents, including protection from abuse. | Type A |
| Failure to immediately call 9-1-1 for an injury or life-threatening medical crisis. | Type A |
| Failure to timely report suspected abuse to law enforcement as required by Welfare and Institutions Code 15630(b)(1)(A)(i). | Type A |
Report Facts
Capacity: 70
Census: 51
Deficiencies cited: 3
Plan of Correction Due Date: Jun 3, 2023
Plan of Correction Sign-in Sheet Due Date: Jun 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director/Administrator | Met with during investigation; involved in incident reporting |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Oversaw licensing program related to the investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 70
Deficiencies: 1
Jun 2, 2023
Visit Reason
The visit was an unannounced Case Management - Deficiencies inspection conducted to investigate a complaint dated September 12, 2022, regarding staff uncertainty about who to report an incident to and delayed police notification.
Findings
The facility failed to ensure a designated administrator was available for staff or that staff knew who to contact regarding an incident, posing an immediate health and safety risk to residents.
Complaint Details
The complaint investigation revealed that staff interviewed did not know who to report the incident to, and management delayed contacting the police by several hours.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure staff knew who the designated administrator was to contact, violating administrator qualifications and duties requirements. | Type A |
Report Facts
Deficiency due date: Jun 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and named in findings regarding administrator availability |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
| Kimberley Mota | Licensing Program Manager | Supervisor named in report |
Inspection Report
Census: 50
Capacity: 70
Deficiencies: 0
May 8, 2023
Visit Reason
The visit was an unannounced Case Management - Incident visit to follow up on self-reported incidents submitted to Community Care Licensing.
Findings
Multiple incidents involving resident altercations were reviewed, with facility staff increasing supervision and making appropriate notifications. No injuries were observed and no deficiencies were cited during the visit.
Report Facts
Incident reports received: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director/Administrator | Met with Licensing Program Analyst during the visit and discussed incidents involving residents. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Capacity: 70
Deficiencies: 2
Apr 11, 2023
Visit Reason
The visit was an unannounced Case Management - Deficiencies follow-up to review self-reported incidents and verbally reported incidents that were not submitted timely to Community Care Licensing (CCL).
Findings
The facility failed to comply with regulations regarding the care of residents with dementia, as a resident was found outside the community without supervision, posing an immediate health and safety risk. Additionally, the facility did not submit incident and death reports to CCL in a timely manner, resulting in a civil penalty.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to address safety measures for residents with dementia, resulting in a resident being found outside the community without supervision. | Type A |
| Failure to submit incident and death reports to the licensing agency within the required timeframe. | Type B |
Report Facts
Civil penalty amount: 1000
Capacity: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director | Met with Licensing Program Analyst during the visit and discussed incidents. |
| Victoria Mozaffari | Health and Wellness Director | Met with Licensing Program Analyst during the visit. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit and authored the report. |
| Kimberley Mota | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 70
Deficiencies: 1
Dec 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations that facility staff did not properly report incidents and that the facility elevator was in disrepair.
Findings
The allegation that facility staff did not properly report incidents was substantiated, specifically that incidents of residents being stuck in the elevator were not reported to Community Care Licensing. The allegation that the facility elevator was in disrepair was unsubstantiated based on document review, interviews, and observations showing the elevator was operational.
Complaint Details
The complaint investigation was substantiated regarding failure to properly report incidents, specifically incidents of residents stuck in the elevator. The elevator disrepair allegation was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit reports to Community Care Licensing when residents were found stuck in the elevator for an extended period of time, violating CCR 87211 Reporting Requirements. | Type B |
Report Facts
Capacity: 70
Census: 77
Plan of Correction Due Date: Dec 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberley Mota | Licensing Program Manager | Oversaw the complaint investigation |
| Susan Edwards | Executive Director | Met with Licensing Program Analyst during investigation |
| Carol Dowell | Administrator | Facility Administrator named in the report |
Inspection Report
Annual Inspection
Census: 46
Capacity: 70
Deficiencies: 0
Dec 1, 2022
Visit Reason
The inspection was an unannounced 1-Year Required Visit focused on infection control procedures and practices at the facility.
Findings
The facility was found to be clean, with proper COVID-19 signage, hand-washing signs, and staff wearing masks. The facility has adequate PPE supplies, daily screening for COVID-19 symptoms, and a cleaning schedule. Fire safety equipment and drills were up to date. No deficiencies were cited during the visit.
Report Facts
Capacity: 70
Census: 46
PPE supply duration: 30
Fire extinguisher last serviced: 2022
Last fire drill: 2022
Document submission due date: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director | Met with Licensing Program Analyst during inspection |
| Victoria Mozaffari | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Capacity: 70
Deficiencies: 0
Oct 11, 2022
Visit Reason
The visit was an unannounced Case Management - Other visit to follow up on two missing documents needed to establish the Regional Director of Operations, Dave Peper, as the Administrator of Cogir of San Rafael until an Executive Director is hired and the Active Administrator's Certificate is processed.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst and Health and Wellness Director discussed the missing documents and confirmed an appointment was made to complete the requirements.
Report Facts
Capacity: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Mozaffari | Health and Wellness Director | Met with Licensing Program Analyst during the visit and discussed missing documents |
| Dave Peper | Regional Director of Operations | Administrator of Cogir of San Rafael until Executive Director is hired |
| Caitlynn Felias | Licensing Program Analyst | Conducted the unannounced Case Management - Other visit |
Inspection Report
Capacity: 70
Deficiencies: 0
Oct 6, 2022
Visit Reason
The visit was an unannounced Case Management - Other visit to follow up on Administrator paperwork and to discuss vaccinations recently conducted at the facility.
Findings
The Licensing Program Analyst conducted a walk-through and observed residents participating in activities and the facility being clean with no exits obstructed. Discussions were held regarding Administrator paperwork and vaccination events. No deficiencies were cited during the visit.
Report Facts
Capacity: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Bannister | Resident Care Coordinator | Met during the visit and involved in facility walk-through |
| Victoria Mozaffari | Health and Wellness Director | Met during the visit and discussed Administrator paperwork and vaccinations |
| Dave Peper | Director of Regional Operations | Responsible for Administrator duties until new Administrator is approved |
Inspection Report
Census: 43
Capacity: 70
Deficiencies: 0
Sep 12, 2022
Visit Reason
The visit was an unannounced Case Management - Other visit to follow up on Change of Administrator paperwork needed due to the previous Administrator, Carol Dowell, no longer being with Cogir of San Rafael. The purpose was to process Dave Peper as the current administrator.
Findings
No deficiencies were cited during the visit. The facility understands that once a permanent Executive Director is established, their paperwork will need to be submitted to Community Care Licensing for review.
Report Facts
Capacity: 70
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Mozaffari | Health and Wellness Director | Met with Licensing Program Analyst during the visit |
| Dave Peper | Regional Director of Operations / Current Administrator | Named as current Administrator overseeing the facility |
| Caitlynn Felias | Licensing Program Analyst | Conducted the unannounced visit |
| Kimberley Mota | Licensing Program Manager | Named in report |
Inspection Report
Original Licensing
Census: 43
Capacity: 70
Deficiencies: 0
Mar 23, 2022
Visit Reason
The inspection was an unannounced Post-Licensing visit conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, safe, and in compliance with regulations, including operational fire extinguishers, smoke and carbon monoxide detectors, emergency preparedness, proper food storage and dietary accommodations, medication security, and sufficient PPE training. No deficiencies were observed or cited during the inspection.
Report Facts
Facility Capacity: 70
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Dowell | Administrator | Met with Licensing Program Analyst during inspection |
| Victoria Mozzafari | Health Director | Met with Licensing Program Analyst during inspection and named in report |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Post-Licensing inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report |
Inspection Report
Original Licensing
Census: 44
Capacity: 70
Deficiencies: 0
Dec 15, 2021
Visit Reason
The inspection was an unannounced pre-licensing visit conducted to evaluate the facility for licensing purposes.
Findings
The facility was found to be clean, with all exits free from obstruction, fire extinguishers charged, and emergency systems functioning. The facility has appropriate care plans for residents with dementia, sufficient food supplies, and provisions for special dietary needs. Staff have been trained and fit tested for COVID-19 PPE use.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Mozzafari | Health Director | Met with Licensing Program Analyst during inspection and involved in facility tour and orientation. |
| Ethelia Hines | Regional Nurse | Met with Licensing Program Analyst during inspection and involved in facility tour and orientation. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the unannounced pre-licensing inspection. |
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