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Inspection visit

Follow-up on corrections

COGIR OF SAN RAFAELLicense 2168040001 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies visit and met with Executive Director/Administrator, Susan Edwards. During the course of the Complaint Investigation dated for September 12, 2022, staff interviewed during the Investigation did not know who to report the incident to. When Staff Member 4 (S4) contacted Management, four hours had passed. Management then did not contact the police for another 3 hours. Per Regulation 87405 Administrator - Qualifications and Duties , “all facilities shall have a qualified and currently certified administrator. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.” The Facility failed to ensure a designated administrator was available for staff and/or staff were unsure who to contact regarding the incident. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC811(Confidential Names),LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468(a)Type A

    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.

  • 87465(g)Type A

    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.

  • 15630(b)(1)(A)(i)Type A

    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.

  • 87405(a)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the June 2, 2023 inspection of COGIR OF SAN RAFAEL?

This was an other inspection of COGIR OF SAN RAFAEL on June 2, 2023. 1 citation were issued: 1 Type A (serious).

Were any citations issued to COGIR OF SAN RAFAEL on June 2, 2023?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87468 Personal Rights:(a)Residents in residential care facilities for the elderly shall have personal rights... those li..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.