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Inspection visit

Incident investigation

COGIR OF FOLSOMLicense 3450029091 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with Regional Vice President of Operation and Interim Executive Director and explained the purpose of the visit. On August 7, 2025, the Department received an incident report regarding a medication error for R1. The incident report revealed that on August 7, 2025, it was discovered by Regional Director of Health and Wellness that R1 has missed all his medications for more than 30 days since R1 does not have an active primary care physician to prescribe refills. LPA and Regional Director of Health and Wellness discussed over the phone that the medication error was brought to the community's attention but it was not addressed until Regional Director of Health and Wellness was informed. Regional Director of Health and Wellness informed LPA that it has since been resolved, R1 now has a primary care physician who has since prescribed refills for medications. As a result of today's visit, deficiencies cited. Please see LIC 809-D. Exit interview conducted and a copy of the report and appeal rights was provided.

Citations

3 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.

  • 87211(a)(1)(D)Type B

    87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...(D) Any incident which threatens the welfare, safety or health of any resident... This requirmenet is not met as evidenced by: Based on file review, Licensee did not comply as LPA received approximately 17 incident reports that exceed the seven days timeframe, which poses a potential risk for residnets in care.

  • 87465(a)(4)Type A

    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 is not met as evidenced by: Based on file review, Licensee did not comply as incident report revealed R1 did not receive medications for more than 30 days which poses an immediate health and safety in care.

  • 1569.319(d)Type A

    §1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interview conducted, Licensee did not comply as R1 managed to escape out of the facility to the locked courtyard, unnoticed for hours by staff, which resulted to an injury, which poses an immediate health and safety risk for residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2025 inspection of COGIR OF FOLSOM?

This was a other inspection of COGIR OF FOLSOM on August 15, 2025. 1 citation were issued: 1 Type A (serious).

Were any citations issued to COGIR OF FOLSOM on August 15, 2025?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports (1) A written report s..."

What type of inspection was this?

This was a 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.