Cogir of North Bay

Type of visit: Required - 1 Year

At approximately 9:25 AM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a required 1-year annual inspection and met with Administrator Davina Barker. Facility is a Residential Care Facility for the Elderly (RCFE) with thirty-seven (37) residents in care. Facility has a Hospice waiver for seven (7) and is approved for twenty-eight (28) ambulatory and fifty-five (55) non-ambulatory residents. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:00 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a four (4) story building, was a comfortable temperature, and passageways were free from obstructions. The fourth floor consists of independent living and is not under the purview of Community Care Licensing (CCL). Fire extinguishers were last inspected 10/25. Smoke and Carbon Monoxide detectors are hardwired and last inspected 10/25. Water temperature in a spot check of ten (10) resident sinks and one (1) hallway sink measured between 106.1- and 119.6 degrees F, which is within the allowable range of 105- to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Spot check of ten (10) Residents' bedrooms were observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. Continued LIC809C... Continued from LIC809... There is a shaded, outdoor seating area with room for activities. LPA observed activity rooms that included libraries, billiards, a salon, and a community center. LPA observed a robust activity schedule posted in prominent areas as well as daily and seasonal activities. Facility has an internet access device and internet available to residents in care, and the phone was observed operational during today's inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 2/26. LPA reviewed emergency disaster plan which was last updated 10/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 12:00 PM LPA conducted a review of eight (8) resident records. All required documentation present. At approximately 1:00 PM LPA conducted review of eight (8) staff records. All required documentation present. At approximately 2:15 PM LPA and Lead MedTech conducted a spot check of medication and medication records. Medication is centrally stored and locked. Davina Barker Administrator Certificate 7002822740 expires 2/22/2026. All fees are current as of this time. Updated copies of the following documents shall be submitted to CCL within 30 days of this visit: Liability Insurance LIC500 - Personnel Report LIC308 - Designation of Responsibility LIC610E - Emergency Disaster Plan No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Feb 9, 2026

Allegation investigated: Licensee not meeting care needs

Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Administrator Davina Barker. Licensee not meeting care needs – Reporting Party (RP) alleges that facility does not maintain residents room leaving sanitation and fall hazards as well as medication mismanagement. During the course of this investigation LPA reviewed records, made observations, and conducted interviews. Review of Housekeeping Guidelines indicated standard tasks that are expected to be completed by housekeeping. Review of Housekeeping Checklist indicated housekeeping signing off and informing residents of completed cleaning. Review of the assigned task sheet indicated all tasks assigned to specific housekeepers including additional requests or comments from residents. Review of Resident Housekeeping Declination form indicated that residents are able to decline housekeeping services. Review of resident LIC602-Physician Report indicated that resident is capable of storing/administering own medication and has the capacity for self-care. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interviews with Housekeeping staff (S1, S2) indicated that resident rooms are split between them and tasks are completed and signed off in the order they are assigned. Further interviews with S1 and S2 indicated that certain residents will ask that only certain tasks be completed and housekeeping will oblige them. Interview with S2 indicated that should they find cleanliness issues not specifically outlined in a resident’s assigned tasks they will clean out of courtesy, as long as the resident agrees. Interview with Administrator indicated there have not been complaints from individual residents regarding housekeeping services. Interview with R1 indicated that facility staff are “really good” and provide assistance when required, however, R1 also stated they are very independent and do not require assistance with medication management or most Activities of Daily Living (ADLs). LPA observed R1 room to be heavily cluttered with objects scattered across the floor and counter tops and a litter box with cat feces. Upon subsequent visits, after R1 agreed to higher levels of cleaning, LPA observed R1’s room to be less cluttered with the floor free of objects and counter tops to be more organized. Although the allegation(s) may have happened or are valid, the Department has found there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 21-AS-20251028103450

Allegation investigated: Facility failed to safeguard residents belongings

Licensing Program Analyst (LPA) A. Canela arrived unannounced for the purpose of gathering more information and delivering findings regarding the above allegation and met with Executive Director/Administrator, Tracy Freudendahl (S1). LPA previously toured the facility, resident (R1) room, toured parking lot, took statements and requested records. It was alleged the facility failed to safeguard residents belongings, when R1 was in the hospital. It was alleged R1s car had been driven and parked in another area and that there were things, including R1's checkbook and keys that were missing from the apartment. LPA toured the area and R1s vehicle was previously located in the front entrance parking lot. S1 had expressed that the car had been there for several months and it has not been moved since R1 left it there. LPA observed the vehicle appeared to have a low tire and observed there were several spider cobwebs around some tires, indicating the vehicle had been there and not moved for an undetermined time. Continue report see LIC9099-C Unsubstantiated LPA previously toured R1s room and observed the refrigerator had food items, R1s clothing items were still in the room. S1 stated the room has been locked, R1s family member was allowed entrance to the room and the facility is unaware if anything was taken by them as it was hard to communicate with them. S1 stated the room has been in the same order that R1 left it, when they went to the hospital. They are unaware of any keys/checkbook or if they are in the room or in possession of R1 or family. R1s daughter does not communicate with facility, but understands R1s daughter made arrangements for R1s vehicle to be picked up. S1 informed LPA that R1s family returned to the facility in January 2025 and took most of the items that were left in R1s room, and did not allow facility staff to document or do an inventory of what was taken. Facility expressed they have reached out to family regarding all of R1s belongings that were left and as of todays date, have not been picked up. Facility has inventoried and documented items left behind for R1 and boxed them. LPA did not get any information from R1s family member as they did not return LPAs call. Based on the above information, and statements received, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, the allegation is UNSUBSTANTIATED. No citations issued today.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 21-AS-20241121135902

Type of visit: Required - 1 Year

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Tracy Freudendahl. Facility provides care and assistance to Older Adults in Assisted Living. Fire clearance is approved for fifty-five (55) non-ambulatory and twenty-eight (28) ambulatory residents. There is an approved hospice waiver for seven (7) residents. The fourth (4th) floor of the facility houses an independent living population that rents apartment units on the property, these are not part of the Residential Care for the Elderly (RCFE) license. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Upon arrival, LPA was informed that there were forty-four (44) residents in care. At approximately 9:25 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:00 AM LPA toured the facility with ED Freudendahl. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offered a variety of menu options for the residents at each meal. Snacks are available for residents. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of ten (10) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. The call system was tested in a resident's room and Caregiver response time was under two (2) minutes. Continued on 809-C... ...Continued from 809 Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 11/2024. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged 1/2025. The last fire drill was conducted on 1/23/2025. The facility conducts fire/emergency drills monthly. At approximately 11:30 AM LPA conducted a sample file review of seven (7) staff members. All staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for eight (8) residents. Upon review, LPA observed residents to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to residents in care. LPA conducted a spot check of five (5) residents’ medications and observed all documentation and medications to be in order and centrally stored. During the tour, residents were observed interacting with staff in common spaces, resting in their private apartments and mingling with family and amongst each other. . The facility provides an eclectic range of activities specified for their assisted living residents. The facility has a hair salon, billiards room, movie room and a country store. During the Inspection LPA observed live music being performed in one (1) of the common areas. Tracy Freudendahl’s Administrator Certification 7006788740 is current with an expiration date of 10/6/2025. LPA is requesting the following documents submitted to Community Care Licensing by 3/14/2025: LIC 308 Designation of Facility Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Copy of Current Liability Insurance No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to Administrator Freudendahl. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 14, 2025

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) A. Canela arrived unannounced for the purpose of continuing complaint investigation and was greeted by Executive Director/Administrator, Tracy Freudendahl. LPA took additional statements and requested records. It was alleged the personal rights of a resident were violated due to a lack of communication by facility staff. Resident R2 was ready to return to the facility after a hospital emergency visit and it was reported Hospital staff made several calls to the facility explaining R2 was ready to be discharged but they were not able to speak with Health Wellness director to coordinate discharge and were just allowed to leave messages by the front staff. It was reported R2 was admitted to the hospital on 8/9/2024 and on 8/13 hospital was trying to discharge R2, but was not able to discharge until 8/15. Continue report see LIC9099-C Unsubstantiated Facility denies the allegations and express they always try to expedite, and conduct assessments of the residents to ensure they can meet their needs. Staff stated they attempted to conduct a visit at the hospital for R2 but the person in charge of giving day passes was not available and staff could not get in as the hospital was not issuing passes. Although the allegation may be true, based on the above information, and statements received, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, the allegation is UNSUBSTANTIATED. No citations issued today.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 21-AS-20240816133812

Allegation investigated: Staff do not ensure that residents are served foods of good quality Staff did not ensure that the facility is maintained in good repair

Licensing Program Analyst (LPA) A. Canela arrived unannounced for the purpose of continuing complaint investigation regarding the above allegations and met with Executive Director/Administrator, Tracy Freudendahl. This investigation included site visits to the facility; statements taken and LPA observations. It has been alleged facility staff do not ensure that residents are served foods of good quality, in that foods are served burned or cold. LPA took several statements from residents and no one corroborated the allegation. Residents expressed they like the food and have never had an issue with food being burned or cold. It was also alleged staff did not ensure the facility is maintained in good repair in that the outside smoking area gazebo tent is torn to shreds and water fountains are not operational. LPA observed the tent is in perfect condition. Facility staff expressed it was replaced about a month and a half ago due to needing a new cover but it was never in shreds. LPA observed water fountain next to the activity room that is not operational and Executive Director explained they were turned off as a precaution ever since Covid-19. They will remove the water fountains as they have several areas with available water and hydrating carts. Although the allegation may be true, based on the above information, and statements received, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, the allegation is UNSUBSTANTIATED. Report email. No citations issued today. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2024 · control 21-AS-20240620122804

Type of visit: Required - 1 Year

LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Executive Director Tracy Fruedendahl. The building for this facility has four floors but the first three are licensed by Community Care Licensing Division (CCLD). The forth floor is independent living and not subject to CCLD. This community is a mix of studio, one bedroom, and two bedroom apartments. Each apartment has a full bathroom and small kitchenette. There are common laundry rooms for residents on each floor. There are several outdoor areas for residents. There are common areas on each floor. Several resident and staff files were checked. The following shall be updated and submitted to CCLD by 02/10/2024: -LIC 500 facility personnel or staff schedule -LIC 308 designation of administrative responsibility -paperwork appointing current executive director -liability insurance Multiple topics were discussed No deficiencies cited.the state’s words, verbatim · CDSS document, Jan 12, 2024

Allegation investigated: Residents needs are not being met by facility

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation included site visits to the facility; statements taken from witnesses and parties; as well as review of documents obtained during the course of the investigation. It has been alleged that the facility has not met R1's needs in that R1 has missed medical appointments; has not set up R1's voice mail; and does not wear a durable medical device prescribed following surgery because staff do not assist R1. The following determinations are made: R1 lives relatively independently with occasional transportation provided by the facility and has not contracted with the facility for additional care; R1's care plan and physician's assessment indicate R1 does not need assistance with activities of daily living; R1's states that R1 has chosen to not attend appointments or wear the medical device on occasions in the recent past. Although the allegation may be true, based on statements and documents reviewed, there is not a preponderance of evidence to prove the allegation is or, is not, true. Therefore, the allegation is UNSUBSTANTIATED. Report left. No citations issued today. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 30, 2023 · control 21-AS-20231019125734

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.