Inspection Reports for Cogir on Napa Road
91 Napa Rd, Sonoma, CA 95476, United States, CA, 95476,
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, showing the facility generally maintained compliance with health, safety, and documentation standards. Several complaint investigations were unsubstantiated, including allegations of staff illegal activity and failure to follow evacuation orders. However, some substantiated deficiencies occurred, primarily involving medication management and resident care, such as a resident missing four days of prescribed medication and a fall resulting in injury due to improper staff assistance. The most recent report from September 23, 2025, cited two deficiencies related to medication omission and inadequate support during ambulation, reflecting ongoing attention needed in these areas. While the facility addressed a staff theft incident with termination and law enforcement involvement, no fines or license actions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 2
Sep 23, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by incident reports received regarding medication omission and a resident fall resulting in injury.
Findings
The inspection found two Type A deficiencies: one involving a resident missing four days of prescribed medication, and another involving improper staff assistance leading to a resident fall and injury. The facility was cited for failure to assist residents with self-administered medications and insufficient competent staff support for ambulation and transferring.
Complaint Details
The visit was complaint-related based on incident reports received on 8/29/25 and 9/15/25 involving medication omission and a resident fall. The fall was recorded on video and reviewed by the Licensing Program Analyst. The complaint was substantiated with deficiencies cited.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident R1 missed 4 days of prescribed Pravastatin Sodium medication. | Type A |
| Staff member S1 did not properly assist resident R2 with walker, resulting in a fall and neck fracture. | Type A |
Report Facts
Deficiencies cited: 2
Plan of Correction Due Dates: One deficiency due 09/24/2025, another due 10/08/2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during inspection and reviewed staff practices. |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed incident reports and video. |
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 0
Sep 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff financially abused residents and did not ensure residents' personal property was safely secured.
Findings
The investigation found that a staff member (S4) was caught stealing money and other items from residents, was arrested, and admitted to thefts involving multiple residents. The facility complied with reporting and security regulations, maintained secure locks and keys, and terminated the staff member immediately upon discovery. However, there was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged staff financially abused residents and failed to secure residents' personal property. The investigation included review of video footage, law enforcement reports, and facility records. The staff member involved was arrested and admitted to theft. Despite this, the allegation was deemed unsubstantiated due to lack of preponderance of evidence to prove the violation.
Report Facts
Facility capacity: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during investigation and provided evidence |
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 105
Deficiencies: 0
Jul 23, 2025
Visit Reason
The inspection was an unannounced Case Management visit triggered by incident reports involving resident health issues and safety concerns, including a staphylococcus aureus infection and falls in the facility.
Findings
The investigation found that resident R1's infection was resolved with no deficiencies cited. Resident R2 experienced two falls with no injuries, but staff used furniture as a fall prevention measure considered a form of restraint, leading to staff suspension and in-service training on restraints and personal rights. Additionally, a theft incident involving staff member S4 was reported and is under investigation. No deficiencies were cited in the report.
Complaint Details
The visit was complaint-related due to incidents involving resident R1's infection and resident R2's falls and restraint concerns. The investigation concluded with no deficiencies cited. Staff involved in the falls incident were suspended pending investigation and completed in-service training. A theft by staff member S4 was reported, investigated by police, and resulted in termination and arrest.
Report Facts
Falls experienced by resident R2: 2
Capacity: 105
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during inspection and involved in incident reporting |
| Alyx Fischer | Health and Wellness Director | Reported on resident R1's condition and involved in investigation of resident R2's falls |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced Case Management inspection |
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 0
Mar 28, 2025
Visit Reason
The inspection was an unannounced Case Management visit triggered by a reported suspected abuse incident involving a resident in the Memory Care unit, specifically concerning an incident where a caregiver allegedly pulled a resident into their apartment causing the resident to fall and hit their head and shoulder.
Findings
The investigation included interviews and review of statements and video evidence related to the incident. The Licensing Program Analyst requested additional documentation and declarations from facility staff and corporate contacts. No deficiencies were cited during this visit.
Complaint Details
The complaint involved suspected abuse of a resident (R1) by an outside agency caregiver (I1) who pulled the resident by the wrist causing them to fall and hit their head and shoulder. The resident was left on the floor until assisted by a Cogir caregiver (S1). Statements from involved staff were collected and video evidence was requested. The Health and Wellness Director was interviewed and tasked with submitting further documentation. No deficiencies were substantiated.
Report Facts
Facility capacity: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during inspection |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Alexandra Fischer | Health and Wellness Director | Interviewed during inspection and responsible for submitting additional documentation |
Inspection Report
Annual Inspection
Census: 105
Capacity: 105
Deficiencies: 0
Feb 7, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and in compliance with safety and health regulations. No deficiencies were cited during the inspection. Documentation for residents and staff was complete, medication storage was secure, and emergency preparedness plans were reviewed with no new updates.
Report Facts
Resident records reviewed: 6
Staff records reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Facility Administrator present during inspection and named in report |
| Christi Coppo | Licensing Program Analyst | Licensing Program Analyst conducting the inspection |
| Elias Magdaleno | Licensing Program Analyst | Licensing Program Analyst conducting the inspection |
| Victoria Bertozzi | Licensing Program Manager | Licensing Program Manager named in report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 105
Deficiencies: 1
Nov 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility administered incorrect medication to a resident in care.
Findings
The investigation substantiated the allegation that a medication technician administered another resident's medication to resident R1, who was taken to the emergency room as a precaution and discharged the same day. The facility reported the incident and took steps to ensure resident safety.
Complaint Details
The complaint alleged that the facility administered incorrect medication to a resident. The allegation was substantiated based on interviews, record review, and evidence that resident R1 received another resident's medication and was taken to the emergency room. The facility notified R1’s responsible party and submitted a Special Incident Report.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to assist residents with self-administered medications as needed, resulting in resident R1 receiving another resident’s medication, posing an immediate health, safety, and/or personal rights risk. | Type A |
Report Facts
Capacity: 105
Census: 75
Deficiency count: 1
Plan of Correction Due Date: Nov 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during investigation and discussed findings |
| Christi Coppo | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Victoria Bertozzi | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 65
Capacity: 105
Deficiencies: 0
Feb 20, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and in compliance with safety and health standards. All required resident and staff records were present and up to date. No deficiencies were cited during this inspection.
Report Facts
Residents on hospice: 9
Resident records reviewed: 5
Staff files reviewed: 5
Fire extinguisher last inspection date: Nov 21, 2023
Smoke/CO detectors last inspection date: Feb 5, 2024
Elevator permit expiration date: Nov 29, 2023
Last quarterly disaster drill date: Feb 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Facility Administrator present during inspection |
| Christi Coppo | Licensing Program Analyst | Conducted the annual inspection |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 0
Jun 20, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident visit following an incident report regarding a resident vomiting discolored blood, to review the incident and ensure proper reporting and care plan updates.
Findings
No deficiencies were cited during the Case Management-Incident Inspection. The resident's Primary Care Physician and Responsible Party were notified, and the care plan was updated accordingly.
Complaint Details
The visit was triggered by an incident report forwarded on June 13, 2023, concerning a resident vomiting discolored blood. Proper reporting requirements were met, and the resident transitioned back from the medical facility. The incident was discussed and reviewed during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during inspection and disclosed care plan updates. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 73
Capacity: 105
Deficiencies: 0
Jan 27, 2023
Visit Reason
The inspection was a required 1-year unannounced inspection focused on infection control practices and procedures at the facility.
Findings
The facility was found to be clean and in good repair with no deficiencies cited. Safety equipment and infection control measures were adequate, including locked medications, operational fire and smoke detectors, and sufficient personal protective equipment.
Report Facts
Days to submit requested documents: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 105
Deficiencies: 0
Jan 26, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff engaged in illegal activity while on the facility grounds.
Findings
The investigation found the facility to be clean and safe with no obstructions. After reviewing staff files, incident reports, and interviewing staff and residents, the allegation could neither be proven nor disproven and was therefore unsubstantiated.
Complaint Details
The complaint alleged staff engaged in illegal activity on facility grounds. The allegation was found unsubstantiated due to lack of preponderance of evidence to prove or disprove the claim.
Report Facts
Capacity: 105
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Wendy Cornejo | Administrator | Facility administrator present during investigation and exit interview |
| Kim Fowlkes | Business Officer Manager | Met with Licensing Program Analyst during investigation |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 105
Deficiencies: 0
Jan 6, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not follow the sheriff's evacuation order during the 2023 Northern California Storm.
Findings
The investigation found the allegation to be unfounded after reviewing evacuation orders and conducting interviews, confirming the facility was never under a mandatory evacuation order.
Complaint Details
The complaint alleged the facility did not follow the sheriff's evacuation order during the January 2023 storm. The allegation was found to be unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 105
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation |
| Wendy Cornejo | Administrator | Facility administrator interviewed during investigation |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 75
Capacity: 105
Deficiencies: 0
Jun 10, 2022
Visit Reason
The inspection was an unannounced Post Licensing visit conducted by the Licensing Program Analyst to evaluate the facility's compliance following licensing.
Findings
The facility was found to be clean and in good repair with no deficiencies observed. Infection control measures including COVID screening and vaccination status were reviewed and found compliant. Medications and toxins were securely stored, and fire safety equipment was inspected and operational.
Report Facts
Residents in memory care: 22
Residents in assisted living: 53
Fire extinguisher last inspection date: Dec 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the Post Licensing Inspection |
| Kim Fowlkes | Business Office Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Original Licensing
Census: 72
Capacity: 105
Deficiencies: 0
Mar 15, 2022
Visit Reason
The inspection was an unannounced pre-licensing visit conducted to evaluate the facility for licensing approval.
Findings
The facility was found to have appropriate furnishings, safety features including fire safety equipment and emergency generator, secured medications, and sufficient food supplies. Staff files and resident records were reviewed and found compliant with mandated reporter documentation, background clearances, and training requirements.
Report Facts
Residents in memory care: 22
Residents in assisted living: 50
Residents on hospice: 2
Fire clearance capacity non-ambulatory: 90
Fire clearance capacity bedridden: 15
Staff files reviewed: 10
Staff files with mandated reporter documentation: 10
Staff files with first aid training: 10
Staff files with CPR training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Census: 64
Capacity: 105
Deficiencies: 0
Dec 2, 2021
Visit Reason
The visit was conducted as part of a change of ownership (CHOW) application process for the facility, including a telephone call with the applicant and administrator to confirm understanding of licensing requirements.
Findings
The applicant and administrator successfully completed Component II of the licensing process, confirming understanding of facility operation, staff qualifications, program policies, and other regulatory requirements. No deficiencies or violations were noted in the report.
Report Facts
Capacity: 105
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Cornejo | Administrator | Facility administrator participating in licensing evaluation |
| Benoit Levesque | Applicant | Applicant participating in licensing evaluation |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on report |
| Victoria Christiansen | Licensing Program Analyst | Named as Licensing Program Analyst on report |
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