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Inspection visit

complaint

COGIR OF FOLSOMLicense 3450029092 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

LIC 9099-C Allegation: Licensee did not ensure staff qualified to assigned duties. The Department conducted a file review which revealed that staff (S1) has been employed with the facility since September 2024 and recently was placed on leave in August 2025. File review of Guardian revealed that S1 required a criminal record exemption in order to work at the facility. A criminal record exemption request was sent to facility on September 21, 2024. Additionally, a letter of case closure was issued on November 18, 2024 due to no response. Live scan was then resubmitted on April 8, 2025 which facility was issued another criminal record exemption request on April 28, 2025 which then a letter for case closure was issued on June 29, 2025 due to no response. Interview revealed that Executive Director was made aware that S1 needed to get the exemption granted in order to work at the facility, but S1 continued to work at the facility until August 2025. The allegation is substantiated as prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall obtain a California clearance or a criminal record exemption. Allegation: Staff mismanaged residents’ medications. Based on file review of resident (R1) electronic medication administration records (e-MAR), it revealed that R1 was prescribed pentoxifylline 400MG tablets to take one tablet by mouth daily, effective February 11, 2025. File review of R1's July 2025 and August 2025 e-MAR revealed that on Sunday, August 3, 2025, medication technician failed to administered R1 a dose of pentoxifylline as there is no initials observed. Medication audit was conducted with medication technician of R1's pentoxifylline bubble pack and it revealed that the pack contains 30 tablets. Bubble pack was dated, opened on "7/23/25". From July 23, 2025 to date of visit, August 19, 2025, there should have been 28 tablets given if administered as prescribed but based on medication audit, there was only 27 tablets administered, which confirmed the missing initial on August 3, 2025. Based on the information obtained, the allegations are SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-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.

  • 87411(g)(1)Type A

    87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption... This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply as S1 has been working at the facility since September 2024 when an exemption request has not been completed, which poses a potential risk for residents in care.

  • 87465()Type B

    87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance... (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on file review and medication audit, Licensee failed to comply as R1 was not administered one dose of pentoxifylline as prescribed, which poses a potential risk for resident in care.

  • 87405(d)(2)Type B

    87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on interviews, Licensee did not comply to the section cited above as Executive Director knowingly failed to comply with criminal record regulations as well as failure to assist resident to ensure medications are given as prescribed, which poses a potential risk for residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 19, 2025 inspection of COGIR OF FOLSOM?

This was a complaint inspection of COGIR OF FOLSOM on August 19, 2025. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to COGIR OF FOLSOM on August 19, 2025?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and vo..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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.