COGIR OF SAN RAFAEL

Official classification

Type B

Official code

87705(e)(7)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee provided proof of elopement training dated 02/04/2026 and 02/18/2026. Deficiency cleared during visit.

Deadline recorded: May 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit self-certification that training will be conducted for all care staff reviewing equipment expectations by POC due date of 12/29/2025. In-service training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. In-service training to be submitted to CCL by POC due date of 01/09/2025.

Deadline recorded: Dec 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 12/15/2025 Plan of Correction Licensee to obtain needed emergency supplies and submit proof of supply by POC due date of 12/15/2025.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 12/15/2025 Plan of Correction Licensee to conduct in-service training for kitchen staff reviewing proper food labeling and storage. Training to include the following: Date, Topic, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date 12/15/2025.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 12/15/2025 Plan of Correction Licensee to submit a water temperature log with temperature checks twice a day. Log to include date, resident room number, water temperature, and time of temperature check. Log to be submitted by POC due date of 12/15/2025.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee provided proof of training that was conducted on 09/25/2025 on " The Six Rights " for staff that administer medications. Deficiency cleared during visit.

Deadline recorded: Oct 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Facility conducted elopement training on 07/31/2025 and 08/04/2025. Deficiency cleared during visit and Plan of Corrections Letter provided.

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit self-certification that all care staff will receive training on the personal rights of residents by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

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 met as 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.

Official plan of correction

Licensee to submit self-certification that all care staff will receive training on facility fall protocol by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

15630(b)(1)(A)(i)

Regulation authority

HSC

What the official deficiency says

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.

Official plan of correction

Licensee to submit self-certification that all care staff will receive training on Reporting Requirements by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Facility to submit the following documents: Lifeline Senior Living Receipt of Repairs and Audit of Resident Pull Cords to be done by Maintenance Director to ensure that they are operable. Documents to be submitted by POC due date of 03/24/2025.

Deadline recorded: Mar 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee to schedule training with vendor for First Aid/CPR certification for all direct care staff. Licensee to provide training date to CCL by POC due date of 01/24/2025. LIcensee to submit staff roster with job titles and proof of First Aid/CPR certificates to CCL by 02/03/2025.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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 in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee to submit self certification that medication training will be conducted for all staff that administer medications by POC due date of 01/24/2025. Training to include the following: Trainer, Date of Training, Topics, Job Role, Staff Names and Signatures. Proof of Training to be submitted to CCL by POC due date of 02/03/2025.

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

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.

Official plan of correction

Licensee to conduct training reviewing the requirements of HSC 1569.657(a) with Managerial Team. Training to include the following: Date of Training, Training Topics, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 08/19/2024.

Deadline recorded: Aug 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit self-certification stating that they have reviewed the regulation. Certification to be submitted to CCL by POC due date of 08/19/2024.

Deadline recorded: Aug 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

LPAs notified the medication technician on duty who immediately put the medications away and locked the cart. Licensee to submit self certification that training for Regulation 87705(f)(2) will be conducted for all Medication Technicians by POC due date of 04/24/2024. Training to review items that are inaccessible to residents in care and to review proper storage of medications. Licensee to conduct Inservice Training and submit a sign in sheet to CCL that includes the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 05/2/2024.

Deadline recorded: Apr 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering... This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 02/15/2024 Plan of Correction Licensee to submit self-certification stating that an in-service training will be conducted with all care staff regarding Elopement Procedures by POC due date of 02/15/2024. In-service training to include the following: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 02/25/2023.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 01/30/2024 Plan of Correction Licensee to submit self certification that training for Regulation 87705(f)(2) will be conducted for all staff by POC due date of 01/30/2024. Training to review items that are inaccessible to residents in care. Licensee to conduct Inservice Training and submit a sign in sheet to CCL that includes the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 02/08/2024.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit self certification that training on Regulation 87705(f)(2) will be conducted for all staff by POC due date of 07/15/2023. Training to review items that are inaccessible to residents in care. Licensee to conduct Inservice Training and submit a sign in sheet to CCL that includes the following: Date,Training Topic, Name/Job Role, and Signatures by POC due date of 07/25/2023.

Deadline recorded: Jul 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to ensure all staff are aware of who to contact in the event of an emergency or resident incident. Licensee to review with staff who the Administrator is and who the Designated Representative shall be in the event the Administrator is unavailable. Licensee to submit a sign in sheet to CCL that includes the following: Date, Name/Job Role, and Signatures by POC due date of 06/12/2023.

Deadline recorded: Jun 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit certification that training on Personal Rights will be conducted for all staff by POC due date of 06/03/2023. Licensee to conduct Personal Rights Training and submit a sign in sheet to CCL that includes the following: Date, Name/Job Role, and Signatures by POC due date of 06/12/2023.

Deadline recorded: Jun 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit certification that training on Reporting Requirements will be conducted for all staff by POC due date of 06/03/2023. Licensee to conduct Training for Reporting Requirements and to review who the Administrator is and who the Designated Representative is in the absence of the Administrator. Licensee to submit a sign in sheet to CCL that includes the following: Date, Name/Job Role, and Signatures by POC due date of 06/12/2023.

Deadline recorded: Jun 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

15630(b)(1)(A)(i)

Regulation authority

HSC

What the official deficiency says

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.

Official plan of correction

Licensee to submit certification that training on Reporting Requirements will be conducted for all staff by POC due date of 06/03/2023. Licensee to submit a sign in sheet to CCL that includes the following: Date, Name/Job Role, and Signatures by POC due date of 06/12/2023.

Deadline recorded: Jun 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit receipt of alarm system inspection by POC date of 04/12/2023. LPA was provided with a copy of receipts during visit. POC cleared.

Deadline recorded: Apr 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(1)(a)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 04/21/2023.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(1)(a)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 12/23/2022.

Deadline recorded: Dec 23, 2022. A deadline is not proof that correction was completed.