Cogir of San Rafael

87705 Care of Persons with Dementia (e) Licensees that use delayed egress devices...shall meet...requirements: (7) Delayed egress devices shall not substitute for trained staff...including staff needed to escort residents who need supervision to leave the facility. Requirement was not met as evidenced by: based on record review, Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility and was found in a car in the parking lot. R1's assessment stated they can't leave unassisted. This poses an potential health/safety risk to persons in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to...Section 87468.1... residents...shall have...following personal rights: (4) To care, supervision, and services that meet their...needs and are delivered by staff that are sufficient in numbers, qualifications & competency...Requirement was not met as evidenced by: based on record review & interviews, Licensee did not comply with section cited above & did not ensure that R1's pendant call was responded to timely. This poses a potential health/safety risk to residents in care.

Based on observations made, Licensee did not comply with the section cited above and did not ensure that there was adequate emergency water supply in the event the facility had to shelter in place for at least 72 hours. This poses/posed a potential health, safety or personal rights risk to persons in care.

Diet quality and preparation in safe healthful manner

Based on observations made, Licensee did not comply with the section cited above. LPA observed 5 instances of unlabeled and undated foods in facility’s fridge. This poses/posed a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observations made, Licensee did not comply with the section cited above. 4 out of 8 residents’ sinks measured at 120.7F, 120.2F, 121.4F, and 122.1F. This which poses a potential health, safety or personal rights risk to residents in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care:(a)A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review, Licensee did not comply with the section cited above and did not ensure that medication was administered to the correct resident as required. Incident Report stated that R1's medication was given to R2. This is an immediate health and safety risk to residents in care.

Auditory exit monitoring for elopement risk

87705 Care of Persons with Dementia: (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement...This requirement was not met as evidenced by: based on record review, Licensee did not ensure that staff were aware that R2 left the facility without assistance. This poses an immediate health and safety risk to residents in care.

Welfare and Institutions Code: 15630(b)(1)(A)(i): "Any mandated reporter who...has knowledge of an incident...shall report...within two working days (A)If the suspected... abuse occurred in a long-term care facility...(i)...report shall be made within two hours of the mandated reporter...obtaining knowledge of...physical abuse." Requirement not met as evidenced by: based on interviews, record review, and observations, Licensee did not comply with section cited above and did not ensure that R1's suspected abuse was reported timely. This is an immediate health and safety risk to residents in care.

Dignity in personal relationships

87468.1 Personal Rights of Residents in All Facilities:(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure R1's personal rights. R1 was shown to be handled roughly by S1 while being provided incontinence care. This is an immediate health and safety risk to residents in care.

Maintain and operate facility under definitive plan

87208 Plan of Operation:(a)The licensee shall have and maintain a current, written definitive plan of operation...The licensee shall operate the facility in accordance with the terms specified... pursuant to Health and Safety Code…This requirement was not metas evidenced by: Based on record review, interviews conducted, and observations made, Licensee did not comply with section cited above. Licensee did not ensure that facility staff followed protocol and ensure that R1 was evaluated timely after hitting their head from a fall. This is an immediate health and safety risk to residents in care.

87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and...separate floors or buildings shall have a signal system...(A) Operate from each resident's living unit. This requirement was not met as evidenced by: based on interviews and document review, Licensee did not comply with the section cited above and did not ensure that facility's pull cord system was operating as required. This poses a potential health and safety risk to residents in care.

Based on record review, Licensee did not comply with the section cited above. 5 of 6 direct care staff members did not have current first aid certification. 3 of 6 direct care staff members did not have current CPR certification. This poses an immediate health and safety risk to residents in care.

Assist residents with self-administered medication

Based on record review, Licensee did not comply with the section cited above and did not ensure that Resident 2's medication was administered as required. Incident Report stated that R2 did not receive their medication on 01/14/2025. This is an immediate health and safety risk to residents in care.

Prompt responses to resident communications

87468.1 Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirment is not met as evidenced by: Based on document review and interviews conducted, facility did not ensure communication with R1’s representative was answered promptly and appropriately as required by regulation. This poses a potential health and saftey risk to residents in care.

HSC 1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative...written notice of the rate increase within two business days... This requirement was not met as evidenced by: Based on document review and interviews, Licensee did not comply with the section cited above and did not ensure proper notice was provided within two days to resident and/or their responsible party as required. This poses a potential health and safety risk to residents in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication... alcohol... and toxic substances...This requirement is not met as evidenced by: Licensee did not comply with the section cited above. LPAs observed medication cart was unattended and unlocked. LPAs observed routine and narcotic medications were on top of the unlocked cart. This poses an immediate health and safety risk to residents in care.

Night supervision when dementia residents require it

Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility and at the end of the facility’s driveway. R1’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.

Fire approval and staff access to unlock systems

Based on documents reviewed, Licensee did not comply with the section cited above. A bottle of wine was observed to be in R1’s room. This poses an immediate health and safety risk to residents in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia:(2)Over-the-counter medication... alcohol... and toxic substances...This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not comply with the section cited above. An opened alcoholic beverage was observed to be in R1’s room. This poses an immediate health and safety risk to residents in care.

87468 Personal Rights:(a)Residents in residential care facilities for the elderly shall have personal rights... those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities... This requirement was not met as evidenced by: Based on interviews conducted and review of documents, the Licensee did not comply with the section cited above, and did not ensure the Personal Rights of R1. This poses an immediate health and safety risk to residents in care.

Call 9-1-1 for imminent health threats

87465 Incidental Medical and Dental Care:(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...an apparent life-threatening medical crisis... This requirement was not met as evidenced by: Based on interviews conducted and review of documents, the Licensee did not comply with the section cited above, and did not ensure that 911 was called for R1. This poses an immediate health and safety risk to residents in care.

Welfare and Institutions Code section 15630(b)(1)(A)If the suspected... abuse occurred in a long-term care facility...(i)a telephone report shall be made to the local law enforcement agency immediately...no later than within two hours... This requirement was not met as evidenced by: Based on interviews conducted and review of documents, the Licensee did not comply with the section cited above, and did not report suspected abuse timely. This poses an immediate health and safety risk to residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties:(a) All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility...coverage by a designated substitute...shall... be responsible and accountable for management...of the facility... This requirement was not met as evidenced by: Based on interviews conducted, the Licensee did not comply with the section cited above, and did not ensure staff knew who the designated administrator was to contact. This poses an immediate health and safety risk to residents in care.

Night supervision when dementia residents require it

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia...(2)Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.This requirement was not met as evidenced by: Based on review of documents, the Licensee did not comply with the section cited above. Resident was found outside of the community without facility supervision and is unable to leave unassisted. This poses an immediate health, safety or personal rights risk to residents in care.

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on interviews conducted and email correspondence, the Licensee did not comply with the section cited above. Licensee did not submit incident or death reports to CCL in a timely manner. This poses a potential health and safety risk to residents in care.

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on interviews conducted and review of documents, the Licensee did not comply with the section cited above, and did not submit reports to CCL when residents were found stuck in the elevator for an extended period of time. This poses a potential health and safety risk to residents in care.