Cogir of Sonoma Plaza

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegation. LPA met with Administrator Wendy Cornejo. Complaint alleges staff mismanaged resident's medication. Complainant states that R1 did not receive their blood pressure medication. During investigation, LPA reviewed medication administration record (MAR). MAR shows resident did miss two (2) doses of their prescribed medication. Per facility, a 40-count supply was delivered to facility on 3/9/26 however the prescription did not include any refills. Staff did not verify that quantity received matched doctor’s orders and Centrally Stored Mediation Log (CSML). Per interview with staff, facility did not realize that the quantity received was 40 rather than 90. Facility initiated request for refill to prescribing physician on 3/22/26. Facility also reached out the R1’s family member to Continued on 9099C... Substantiated Continued from 9099A... review, facility never received response from doctor. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED Complaint alleges facility staff did not ensure resident's care needs were met. Complainant states staff did not ensure R1 was bathed. During investigation, LPA reviewed facility shower logs dated from February 2026 through May 2026. R1’s is shown to have received showers, sponge baths, and logs also reflects shower refusals. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges staff did not repair faulty wire that sparked when moved. Complainant states that R1’s room had an outlet that housed a faulty wire which gave off sparks. During investigation, LPA reviewed photographic evidence presented to LPA. Photographic evidence did not show a spark or any wires exposed from electrical outlet cover and face plate. Face plate shown as slightly off center. During investigation, LPA conducted interviews. Six (6) out of seven (7) staff report never having seen any sparks or faulty wires from the outlet, only that there was sometimes an issue with the switch being in the off position and therefore the items plugged into that outlet would not work, because the switch was in the off position. One (1) staff reported that they didn’t know of any faulty outlet period. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges facility did not issue a proper eviction to resident. Complainant states that R1 received an eviction notice from facility. During investigation, LPA conducted interviews. It was reported to LPA that R1’s family are the ones that provided a 30 notice to the facility of their intent to remove the resident. It was also reported to LPA that R1’s care levels exceeded the care that the facility could provide and therefore R1 would be leaving the facility. During investigation, LPA received conflicting accounts of why resident left facility. During the course of investigation, LPA did not receive any documentation or photographic evidence of any eviction notice served to R1 or their responsible party by facility. Facility denies issuing any such eviction notice. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Admin and a copy of this report given. Continued from 9099... advise R1 was out of medication. R1 missed two (2) does on 3/23/26. Facility received refill of medication on 3/24/26. However, facility could not show proof of request earlier than 3/22/26. So, based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Exit interview conducted with Admin and a copy of this report given.the state’s words, verbatim · CDSS document, Aug 28, 2026 · control 21-AS-20260610153456

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 31, 2026

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 not met by licensee as evidenced by: Based on LPA interview and record review, R1 missed two (2) doses of their verapamil, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: Facility to conduct in-service training on medication management. Training to include updated policy on how facility will ensure the quantity of pills they receive match both the doctor's orders and the Centrally Stored Medication Log (CSML). Facility to submit log and policy to CCL by POC date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a case management visit. LPA met with Administrator Wendy Cornejo. On 7/31/26 CCL received a Suspected Abuse report (SOC341) from facility. Facility staff (S1) reported suspected abuse by facility staff (S2) toward resident (R1). Report indicates that S1 suspected that S2 pulled R1 harshly onto chair with force, which S1 believes resulted in a bruise on the R1's bottom. S1 also reported hearing S2 belittle R1 by stating they were stupid and that they had no brain because of their dementia disease. LPA conducted interview with S1 about report submission. S1 reported to LPA that they observed the alleged abuse on only one occasion, this occasion. S1 reported to LPA that they reported the alleged abuse to facility Admin on 7/30/26. LPA met with Admin and discussed report of abuse. Admin became aware of alleged abuse on 7/30/26. Upon learning of the alleged abuse, Admin held meeting with S2 and subsequently S2 was suspended. On 8/6/26 S2 was terminated. Admin will forward to CCL the termination paperwork for S2. No citations issued during this visit. Exit interview conducted with Admin and a copy of this report given.the state’s words, verbatim · CDSS document, Aug 12, 2026

Allegation investigated: Staff are not properly assessing residents for a higher level of care Resident's care needs are not being met

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to deliver findings on the above allegations. LPA met with Administrator Wendy Cornejo. Complaint alleges residents R1, R2, R3, and R4 are not being properly assessed for a higher level of care. Complainant states these residents should be housed in Memory Care (MC) rather than Assisted Living (AL). During investigation LPA reviewed documents and conducted interviews. Per facility Administrator (Admin) at the initial resident assessment, the facility administers a Saint Louis University Mental Status (SLUMS) exam; a certain score lends to the resident being placed in either MC or AL. A resident’s preplacement appraisal, physician’s report, and their SLUMS exam score are all factored into the placement decision. After their initial exam, they have an assessment every 6 months or if they have a change in condition. During investigation, LPA reviewed the physician’s reports for R1, R2, R3, and R4. Continued on 9099C... Unsubstantiated Continued from 9099A... Complainant states that facility has been administering scheduled morphine but there are no nurses on site at facility. During investigation, LPA reviewed orders for all those residents prescribed morphine. All orders for liquid morphine are filled by the pharmacy via pre-filled/pre-dosed syringes and it is delivered via syringe for self-administration. Complaint alleges residents (R6 and R7) uses a zinc menthol cream, but the cream was never reordered when out of stock. Complainant states facility has instructed staff to use regular zinc cream without the menthol on the residents. LPA reviewed medication orders for R6 and R7. R7 did not have an active prescription for zinc menthol cream. R6 did have a prescription for both menthol and zinc cream. LPA reviewed e-MAR for R6. LPA observed e-MAR entries for R6 indicating the zinc cream was listed as “DNA” which stands for drug not available. During investigation, LPA conducted interviews. Facility Admin reported that when she became aware of the medication being listed as DNA on the e-Mar, she held a staff meeting to find out what the issue was. Per Admin, the zinc menthol cream was never out of stock, rather it was being stored in the resident’s bedside drawer rather than medication cart. However, not all staff were informed that the cream was being stored in the bedside table. Prescribed medications that may not be handled by the resident are required to be centrally stored. During investigation, LPA conducted interviews, six (6) out of eight (8) staff report that R1’s cream was stored bedside. Additionally, five (5) out of five (5) staff reported that when a medication is marked “DNA” in the e-MAR nothing is given in its place, because the drug is not available. So, based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given. Continued form 9099... Physician reports for R1, R2, and R3 show a diagnosis of dementia. R4’s physician report does not show a diagnosis of dementia. Per facility Administrator, the MC unit at the facility is impacted. So, facility has a working waitlist that is updated and reviewed monthly. LPA reviewed waitlist and found that R1 and R2 were on the waitlist, and R3 was under consideration for addition to the waitlist, pending a family and physician conference. Per facility Administrator, interventions are put in place for those residents placed on the waitlist such as increased monitoring, usually every 2 hours, but sometimes every hour. Facility also conducts care conferences with the family to let them know of the issue(s) and/or the need to be moved and go over costs and options. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges resident (R3) care needs not being met. Complainant states that sometime around the end of February 2026, they observed R3 to have unexplained bruising on their legs. During investigation, LPA conducted interviews and review of R3’s chart notes. Chart notes did not note any bruising. Four (4) staff out of five (5) staff reported they never observed any bruising on R3’s legs. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Administrator and a copy of this report given.the state’s words, verbatim · CDSS document, May 28, 2026 · control 21-AS-20260311115010

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 29, 2026

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 requremient not met by licensee as evidenced by: Based on LPA interview and record review R3 did not receive incontinence care with prescribed medication cream, which poses an immeidate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Facility held a meeting to discuss medication management and conducted training with all staff administering medication on 4/6/26. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: May 29, 2026

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement not met by licensee as evidenced by: Based on LPA interview, S1 was abusive toward R3, which poses an potential health, safety, and/or personal rights risk to resident in carethe state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Facility immediately issued corrective disciplinary action and conducted training with S1 on 3/11/26. Deficiency cleared

Allegation investigated: Resident sustained an injury due to possible neglect or physical abuse

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Administrator Wendy Cornejo. Complaint alleges resident (R1) sustained an injury due to possible neglect or physical abuse. Complainant states that facility staff observed R1 to have a black eye, it was observed while they were getting R1 ready for morning breakfast. Staff questioned R1 about their eye, but R1 made conflicting statements accounting for they received it; initially stating that a person came in the night and struck them but then reporting to the police that they had a bug in their eye. During investigation, LPA conducted interviews. LPA interviewed seven staff. One (1) staff said they did not directly observe R1 to have any bruising of the eye or a black eye, but that staff reported to them that they saw a bruise, three (3) staff reported seeing a bruise or red mark on R1's eyelid, and three (3) staff reported they did not observe R1 to have any bruising or a black eye. Seven (7) out of seven (7) staff report they did not observe anyone hit or strike R1. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 28, 2026 · control 21-AS-20260518155849

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Administrator (Admin) Wendy Cornejo. On 5/28/26 LPA delivered substantiated complaint findings on complaint 21-AS-20260311115010. During investigation, it was reported to LPA that prescription zinc cream was kept in resident (R1's) bedside table for incontinence care. However, prescribed medications that may not be handled by the resident are required to be centrally stored. During investigation, LPA conducted interviews, six (6) out of eight (8) staff report that R1’s cream was stored bedside.(deficiency cited, see 809D). On 5/22/26 CCL received an Incident report from facility indicating residents experienced a medication error. Facility reported that on 5/8/26, the facility experienced an unexpected staffing issue when a scheduled Med Tech called off for their shift. Attempts were made to secure coverage internally through the facility staffing team; however, coverage was unavailable. In order to maintain resident care and medication administration services, the community secured an agency nurse through BrightStar. On the morning of 5/9/26, the AM Med Tech identified medication count discrepancies during reconciliation, prompting an immediate audit and MAR review of the 5/8/26 PM medication pass. The audit confirmed PM medications for residents R2, R3, R4, R5, R6, and R7 were not administered. Upon discovery, Memory Care (MC) director immediately conducted a full medication cart audit and reconciliation pass to ensure no other discrepancies present. Per Admin, residents were assessed for adverse effects and monitored for any changes in condition. All required parties were notified. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 29, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place...This requremient not met by licensee as evidenced by: Based on LPA interview prescribed zinc cream for R1 was left unlocked in bedside table, which poses an immeidate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Facility to submit plan to conduct 1 hour of proper storage of medication training with all staff responsible for medication management by plan of correction due date, Training to be completed no later than 6/11/25

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Administrator (Admin) Wendy Cornejo. On 2/9/26 CCL received an Incident report from facility indicating resident (R1) eloped from the facility. R1 was observed walking along the vineyard area on the side of the facility. R1 became disoriented and thought they could walk behind the facility. As R1 was walking, they realized they were no longer at the facility. R1 waved down a neighbor who was driving by and that neighbor helped R1 back into the facility the same day. R1 was unharmed and facility notified R1’s responsible party and R1’s doctor. Per Administrator, and LPA observation, residents often utilize the rocking chairs outside in front of the facility to enjoy the sunshine and fresh air. These chairs are visible to both the concierge and from the Administrator's office inside the facility. Due to this incident, Administrator will work with upper management to install a gate to the entrance of the facility so that residents can still enjoy a walk through the vineyard located on the side of the facility. Additionally, facility is located off a busy road, especially during high traffic hours. Administrator advised that until the gate is approved and installed, residents will now be utilizing only the interior gardens in which to walk and enjoy the outdoors. Per R1’s physician’s report, R1 is not allowed to leave the facility unassisted. Upon LPA arrival, Admin advised LPA of a recent elopement 2/28/26. New resident (R2) had just moved in the night before later in the evening. On the morning of 3/1/26, R2 had a disagreement with their family member for moving them here and took off walking outside. Later n the morning around 9:30am resident's responsible party noticed they were not in their room, All available staff immediately initiated a search of the building including the courtyard, rose garden, memory care unit, restrooms, and all apartments. At around 9:45am, Health and Wellness Director (HWD) contacted the Administrator to review the front door security cameras. Around 10:00am, the front desk received a call from the fire department advising Continued on 809C... Continued from 809... that they located R2 down the street The fire department and paramedics spoke directly with R2's responsible party and they proceeded to pick up the resident. Per R2's physician's report R2 is not allowed to leave the facility unassisted. (deficiency cited, see 809D) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269 · Plan of correction due date: Mar 6, 2026

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: …(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that R1 and R2 eloped from the facility, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: Facility will submit plan to conduct elopement training for all staff providing care to residents by plan of correction due date. Facility to conduct training no later than 3/12/26. Facility to submit training log to CCL no later than 3/13/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Wendy Cornejo. Administrator certificate 7005339740 expires 7/22/26. LPA and Administrator reviewed staff roster and Guardian roster. All staff associated. At approximately 10:00am LPA, Med Tech and Admin conducted a spot check of medication and medication records. Medication is centrally stored in locked medication carts. No deficiencies cited. At approximately 11:30am LPA and Administrator toured selected rooms in Memory Care (MC) and Assisted Living (AL). Both MC and AL portions of the facility were found to be clean and at a comfortable temperature. LPA observed pull cords and grab bars present in all MC and AL rooms. All bedrooms were clean and in good repair. Water temperatures in Memory Care (MC) measured at 112.5 degrees F in kitchen, 107.1 degrees F in MC room #4 and 105.6 degrees F in MC room #17. Water temperatures in Assisted Living measured at 105.5 degrees F in room #101, 109.6 degrees F in room #111, 109.4 degrees F in room #203, and 107.8 degrees F in room #240 all of which are within the allowable range of 105 to 120 degrees F. LPA and Admin utilized both sets of stairs within facility. LPA observed evacuation chairs present in both stairwells. LPA and Admin toured courtyard area. No obstructions or tripping hazards observed. At approximately 12:45pm LPA conducted a review of seven (7) resident records. No deficiencies cited. At approximately 2:00pm LPA conducted review of seven (7) staff records. No deficiencies cited. Continued on 809C... Continued from 809... At approximately 3:30pm LPA and Admin toured the main kitchen. The kitchen was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA reviewed temperature logs of refrigerator and freezer, all temperatures were within regulation and current. Kitchen water temperature measured at 133.7 degrees F, hot water sign present above one sink. Facility will add caution signs above all other kitchen sinks. First aid kit present. Fire extinguishers were last inspected 12/17/25. Smoke/Carbon Monoxide detectors and sprinklers located throughout the facility are hardwired and serviced by Johnson Controls Fire Protection, last date of quarterly service 12/3/25, all systems passed. Facility is due for five [5] year annual as of 12/8/25; facility produced documentation of communication with vendor indicating appointment for service. Fire alarm serviced by same vendor, last date of service 12/3/25. Report shows one alarm failed; alarm was immediately replaced and is now working. Facility’s last quarterly disaster drill was conducted on 1/14/26. Facility has a backup generator for use during a power outage. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Administrator will send LIC610E for CCL facility file. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Liability Insurance No deficiencies cited. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 12, 2026

Allegation investigated: Facility staff did not meet residents care needs Inadequate Staffing

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegations. LPA met with Administrator Wendy Cornejo. Complaint alleges facility staff did not meet residents care needs. Complainant states that incontinence needs of residents are not being met, that they are found in the morning soaking wet or covered in feces, indicating they had not been changed overnight. During investigation, LPA interviewed witnesses. Three (3) of four (4) witnesses interviewed indicate that they have witnessed the incontinence needs of residents not being met and finding them as the complainant alleges. Complainant alleges facility does not have adequate staffing. Complainant states that often facility’s Memory Care (MC) is short staffed on the NOC shift. California Code of regulations, Title 22 does not have Continued on 9099C... Substantiated Continued from 9099... staffing ratio requirements. However, the facility must be able to meet the needs of residents. So, during investigation LPA reviewed the care plans and medical assessment for all 23 Memory Care residents. Of the 23 residents: · Ambulation: 6 require extensive assistance, 2 require moderate assistance. · Transferring: 4 require extensive assistance, 4 require moderate assistance, 2 require a two-person assist. · Bathing: 11 require extensive assistance, 4 require moderate assistance. · Grooming/Dressing: 8 require extensive experience, 6 require moderate assistance. · Toileting: 4 require extensive assistance, 8 require moderate assistance · Wandering/Sundowning behavior: 6 are reported to have this behavior · Fall risk: 3 are identified as being a high risk, 1 identified as a moderate risk, and 2 identified as low risk During investigation, LPA conducted interviews with witnesses. Four (4) out of six (6) witnesses report that facility's NOC shift is understaffed. LPA received report that medication was not made available to a resident that needed it during NOC shift because there was not a Med Tech or caregiver on duty that could dispense medication. LPA reviewed Memory Care staff schedule. Review of staff schedule shows that at least one Med Tech and 2 caregivers are scheduled each NOC shift. However, on some days schedule shows only one caregiver and one Med Tech for both Assisted Living (AL) and MC; other days it shows only a Med Tech. Per Admin, this is because the facility is utilizing caregivers from registry. Admin states facility needed to hire a NOC shift caregiver permanently and while they were conducting interviews and reviewing candidates for hire they used registry for temporary staff coverage. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D Conitued on 9099C(2)... Continued from 9099C... Note* Admin advised LPA during delivery of findings that facility has addressed incontinence care with NOC shift caregivers. Admin was made aware of residents incontinence issues not being met due to employees inadequate ability to identify needs of residents. Upon learning of issue, Admin immediately addressed caregiver inadequacies by terminating their employment. Admin has since filled the open positions resulting from termination and trained new staff on proper incontinence care. LPA verified records confirming as such, Admin is also adding another caregiver to NOC shift so that ideally there are 2 Med Techs and 2 caregivers for the NOC. Exit interview conducted with Admin and a copy of this report given. Appeal rights given.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 21-AS-20250919160909

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Dec 4, 2025

87625 Managed Incontinence (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requremient not met by licensee as evidenced by: Based on LPA interviews witnesses indicate that they have witnessed the incontinence needs of residents not being met, which poses an potential health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: Facility has addressed incontinence care with NOC shift caregivers. Admin was made aware of residents incontinence issues not being met due to employees inadequate ability to idenitify needs of residents. Admin addressed caregiver inadequacies by immediately terminating their employment. Admin has filled the open positions resulting from termination and trained new staff on proper incontinence care. Admin is also adding another caregiver to NOC shift so that ideally there are 2 Med Techs and 2 caregivers for the NOC. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 4, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requremient not met by licensee as evidenced by: Based on LPA interviews facility did not have adequate staffing to meet residents' needs, which poses an potential health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: Facility was understaffed on the NOC shift. Per Admin, facility was utilizing caregivers from registry in order to fulfill need for caregivers. Admin states facility needed to hire a NOC shift caregiver permanently and while they were conducting interviews and reviewing candidates for hire they used registry for temporary staff coverage. Per Admin, as of mid to late October, the facility has hired a full time NOC caregiver. LPA reviewed staff schedule. Deficeincy cleared.

Allegation investigated: Staff financially abused residents in care Staff did not ensure residents personal property was safely secured

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegations. LPA met with Administrator Wendy Cornejo. Complaint alleges staff financially abused residents in care and staff did not ensure residents personal property was safely secured. Complainant states between at least 2024-2025 Cogir staff member was found to have stolen several thousands of dollars in cash, coins and jewelry from the six noted residents of Cogir of Sonoma Plaza and also appears to have made some unauthorized transactions with a stolen credit card." On 7/22/25, Admin notified LPA of theft in facility. Minor instances of theft were previously reported to LPA earlier in the year, suspect unknown. On 7/21/25 at approximately 7:30pm, staff (S4) was caught on camera digging through a recently deceased resident's (R3) belongings. S4 was observed opening a drawer and pulling out an envelope of money. Money was stolen and put in S4's pocket. On 7/22/25 at Continued on 9099C.... Unsubstantiated Continued from 9099... approximately 10:00am, Admin and HWD contacted Sonoma Sheriff Department (event #SON-250000229 and SON-250000383). Deputy arrived at facility to take report and view video footage of theft. R3's responsible party was notified. At approximately 2:30pm on 7/22/25, S4 was arrested by deputy. Facility immediately terminated S4 as they were being arrested. Case is still being investigated by law enforcement. S4's private residence was searched and additional items of theft from residents of the facility were recovered. Police report pending. Video footage of theft given to LPA. On 7/23/25, LPA visited the facility to conduct a case management about the reported theft and arrest of S4. Facility did submit to CCL the required SOC341 self-reporting the occurrence of theft and they noted abuse of the financial type at the facility by S4. LPA’s review of SOC341 indicates that both law enforcement and the Sonoma ombudsman were also notified. Prior to the incident of theft on 7/22/25, facility reported previous instances of theft to law enforcement: incident submission numbers P2C000177096 regarding resident (R1) and P2C000192304 regarding resident (R2), suspect unknown in each instance. Additionally, facility Administrator recorded the instance of missing items in their Resident Theft and Loss Record, as required by regulation. In April 2025, facility reported instance of theft pertaining to resident (R3) to law enforcement and CCL; event #SO250000229. For this occurrence there were only two staff that had access to the residence of R3. The facility has two sets of master keys, the locations of which are secure such that the keys are safeguarded. So, facility Administrator was able to narrow down the suspects by process of elimination, eliminating those staff that did not have access to the keys to the room of R3. Facility Administrator and facility Health and Wellness Director worked with law enforcement to determine the identity of the thief. During investigation, Administrator provided evidence to LPA showing her correspondence with law enforcement pertaining to the theft. However, law enforcement’s effort to identify the thief did not yield a result. Facility Administrator recorded the instance of missing items in their Resident Theft and Loss Record, as required by regulation. Continued on 9099C(2)... Continued from 9099C... In June 2025, facility had a report of suspected theft, but resident (R4) could not remember if they had misplaced the items in question or if they had indeed been stolen. Nevertheless, facility Administrator recorded the instance of missing items in their Resident Theft and Loss Record, as required by regulation. During investigation, LPA reviewed facility reports to and from law enforcement, facility reports of theft reported to CCL, and facility’s Resident Theft and Loss Record. To the best of LPA’s knowledge and review of documents, facility is found to have been complaint with regulation. Doors to residents rooms all have locking features; locks are present that require a key to open. Facility provides residents with the ability to lock their rooms, ensuring that their personal property can be safely secured. Master keys are kept secure and safeguarded. Additionally, LPA’s investigation of thefts finds that facility maintained compliance with Title 22 regulations in so far as they reported and recorded the instances of theft in compliance with regulation. Facility cannot control the ethical or moral behavior of staff. Upon discovering the identity of the thief, facility immediately terminated S4. Arrest of S4 resulted in S4’s admitting they were the thief behind the previous thefts of R1, R2, R3, and R4. So, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 21-AS-20250805091856

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a case management visit. LPA met with Administrator Wendy Cornejo. On 8/29/25 CCL received an Incident Report from facility indicating that on 8/20/25 staff discovered R1 had missed 4 days of prescribed Pravastatin Sodium (deficiency cited, see 809D). Also on 8/20/25 R1 was taken to the emergency room (ER) due to feeling weakness on their right side. R1 was diagnosed with a UTI and was prescribed antibiotics. UTI not caused by medication error. R1 returned to the community 8/22/25. On 9/15/25 CCL received an Incident Report from facility indicating that on 9/8/25 staff was assisting R2 out of her apartment when R2 lost her balance and fell. R2 subsequently reported having back pian. R2 seen at the hospital where they diagnosed them with a neck fracture. R2 returned to the community the same day. LPA reviewed R2 charting notes. Fall was recorded on Safely You video. LPA reviewed video. LPA observed staff (S1) to place walker out of reach of resident and used it to prop open the door to the apartment. R2 fell to the floor and S1 left resident on floor to go and get help. Administrator reviewed with S1 best practices are to remain with resident and radio/call for assistance as well as how to properly use postural support for ambulation. Resident R2 placed on 72 hr monitoring. R2 was scheduled to have a follow up appointment to assess injury, but had a subsequent fall and returned to the hospital on 9/15/25. LPA reviewed assessment and physician's report for R2. Physicians order on file for walker. Assessment indicates extensive hands on assistance with ambulation and transferring needed (deficiency cited, see 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 24, 2025

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed...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 not met by licensee as evidenced by: based on LPA record review, R1 missed 4 days of prescribed pravastatin Sodium, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Facility to provide to CCL plan indicating they will conduct an in-service training for all medication technicians on all shifts. Plan to be submitted by plan of correction due date. Training to be conducted no later than 10/8/25. .

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Oct 8, 2025

87411 Personnel Requirements - General (a)Facility personnel shall at all times be ... competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. This requirement not met by licensee as evidenced by: based on LPA record review, S1 did not properly assist R2 with walker, resulting in fall, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Facility will conduct Postural Supports training with S1 by plan of correction due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Administrator Wendy Cornejo. On 6/20/25 CCL received an Incident report for resident (R1). Incident report indicated that on 6/10/25 facility was made aware by R1's responsible party that R1's previously diagnosed cellulitis was a staphylococus aureus infection. Facility advised R1's responsible party that staphylococus aureus infections is a prohibited condition. R1 was then seen at their primary care physician the same day, 6/10/25. They then were evaluated at the Emergency Room (ER). The ER diagnosed R1 with septic bursitis of right elbow with a culture of MSSA. MRSA and MSSA are both types of staphylococus aureus, but MSSA is not antibiotic resistant. R1 was then admitted to the ER for antibiotic therapy. R1 was discharged with a diagnosis of traumatic olecranon bursitis with apparent cellulitis. LPA reviewed discharge papers for R1. Papers also note that cellulitis was resolved while in the hospital and infection resolved as well. Discharge papers dated 6/16/25 state that R1 did not need to be in isolation. R1 returned to the facility on 6/16/25. Care plan was updated, Home Health was ordered to monitor R1's elbow, and R1 continued oral antibiotics for approximately one week. Per Health and Wellness Director (HWD), Alyx Fischer, R1's elbow is now healed. No deficiencies cited. On 6/27/25 CCL received an Incident report for Memory Care resident (R2). On 6/27/25 R2 experienced two [2] falls in their room, one at 3:36am and one at 10:58pm. Falls captured on Safely you video and alerted staff. R2 was assessed by staff S1 and S2, no injuries observed by staff or reported by R2. After fall #1, R2 was assisted back into bed and S1 placed R2's wheelchair and their recliner next to R2's bed. After fall #2, R2 was helped back into bed by staff S3 and S1. Once again, S1 placed R2's wheelchair next to her bed. Continued on 809C... Continued from 809... Upon learning of the incident, HWD observed and interviewed R2, they did not recall having their furniture moved to prevent them from falling out of bed. Memory Care Director (MCD) notified R2's Power of Attorney (POA). All involved team members were placed on suspension pending an internal investigation. HWD reported to Sonoma Sheriff's office (event ID# SO251780006) and MCD, HWD, and Admin all interviewed S1, S2, and S3. S1 reported that they were trying to use the wheelchair and recliner as a fall prevention measure, they did not know it would be or could be considered a form of restraint. Investigation concluded approximately on 7/2/25 and S1 returned to work 7/1/25. S2 and S3 returned to work on 7/2/25. To address the issue of restraints and personal rights, facility conducted in-service training starting on 7/1/25 and concluding on 7/14/25, for all direct care staff. Training topics covered were restraints, personal rights, and mandated reporting. S1, S2, and S3 all participated in the in-service training. No deficiencies cited. On 7/22/25, Admin notified LPA of theft in facility. Minor instances of theft were previously reported to LPA earlier in the year, suspect unknown. On 7/21/25 at approximately 7:30pm, staff (S4) was caught on camera digging through a recently deceased resident's (R3) belongings. S4 was observed opening a drawer and pulling out an envelope of money. Money was stolen and put in S4's pocket. On 7/22/25 at approximately 10:00am, Admin and HWD contacted Sonoma Sheriff Department (event #SON-250000229 and SON-250000383). Deputy arrived at facility to take report and view video footage of theft. R3's responsible party was notified. At approximately 2:30pm on 7/22/25, S4 was arrested by deputy. Facility immediately terminated S4 as they were being arrested. Case is still being investigated. S4's private residence was searched and additional items of theft from residents of the facility were recovered. Police report pending. Admin will forward S4's information to CCL by 7/28/25. Video footage given to LPA. No deficiencies cited. Exit interview conducted with Admin and a copy of this report given.the state’s words, verbatim · CDSS document, Jul 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management inspection and was greeted by Administrator, Wendy Cornejo. On 3/17/25 CCL received SOC341 from facility reporting suspected abuse of resident (R1). SOC341 indicates R1 is a resident of the Memory Care unit at facility. SOC341 indicates that on 3/15/25 outside agency caregiver (I1) was assisting R1 to their apartment. R1 was resistant to entering their room, so I1 grabbed R1 by the wrist and pulled R1 into their apartment. R1 was pulled such that they lost their footing/balance and hit their head on the closet door knob as well as their left shoulder as they fell to the floor. I1 did not call for help and did not assist R1 up from the floor. I1 then proceeded to lock the apartment door and move about the apartment shutting blinds and adjusting the bedding. R1 remained on the floor until Cogir caregiver (S1) entered the room. S1 immediately performed injury assessment and wellness check on resident. After no injuries were assessed, S1 then helped R1 up with the assistance of I1. Written statement of S1's account of the incident was submitted to CCL at time of SOC341 submission. S1 states that upon entering R1's apartment she found R1 on the floor. S1 asked I1 what happened. I1 reported to S1 that R1 had become tired and needed to sit down, so I1 pulled the ottoman over for R1 to sit on, but R1 "kind of rolled off" the ottoman, which is why R1 was now on the floor. S1 then assisted R1 up off the floor and proceeded to help R1 with toileting needs before helping R1 in bed to rest. During visit, LPA interviewed Health and Wellness Director (HWD), Alexandra (Alyx) Fischer. LPA viewed Continued on 809C... Continued from 809... video record evidence of incident. LPA requested video record be submitted to CCL. Record release requires CDSS written request to be submitted by Licensing Program Manager (LPM). LPA will submit LPM written request to facility once obtained. LPA asked HWD if S1 would be willing to sign and date their written statement that was submitted with SOC341. S1 was not present at facility during LPA visit so HWD will ask S1 and forward to CCL if S1 agrees to sign and date their statement. LPA requested HWD complete a LIC855 Declaration, documenting her accounting of Cogir response to incident and any applicable or additional information has about the incident and I1. HWD will check with corporate Cogir contact as to corporate policy around providing LIC855 Declaration to CCL. HWD will submit LIC855 if/when corporate gives their approval. Exit interview conducted with HWD and a copy of this report given. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 28, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Christi Coppo and Elias Magdaleno arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Wendy Cornejo. Facility contact information was reviewed. At approximately 10:30am LPAs and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPAs reviewed temperature logs of refrigerator and freezer, temperatures documented within regulation. Kitchen water temperature measured at 130.2 degrees F, hot water sign present above one sink. Facility staff immediately added caution signs above all other kitchen sinks. First aid kits present and fully stocked. LPAs toured selected rooms in assisted living and memory care. LPAs observed pull cords and grab bars present in all rooms. All bedrooms were clean and in good repair. Water temperature measured 109.2 degrees F in room 108, 109.8 degrees F in room 126, and 109.4 degrees F in resident accessible memory care kitchen, which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 12/30/2024. Smoke/Carbon Monoxide detectors, sprinklers located throughout the facility are hardwired and serviced by a vendor, last date of service 12/20/2024. Facility’s last quarterly disaster drill was conducted on 11/20/2024. LPAs and Admin discussed conducting emergency drills every quarter. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... At approximately 12:45pm LPAs conducted a review of six (6) resident records. All required documentation present. At approximately 1:30pm LPAs conducted review of six (6) staff records. All required documentation present. At approximately 3:00pm LPAs and Health and Wellness Director conducted a spot check of medication and medication records. Medication is centrally stored in locked medcarts. No deficiencies Wendy Cornejo Administrator Certificate 7005339740 expires 7/22/2026. All fees are current as of this time. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Liability Insurance No deficiencies cited. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 7, 2025

Allegation investigated: Facility administered the incorrect medication to resident in care

Licensing Program Analyst (LPA) Coppo met with Administrator Wendy Cornejo to investigate a complaint regarding the allegation of “facility administered the incorrect medication to resident in care." Complaint alleges a medication technician at facility administered another resident’s medication to resident listed as R1. R1 was taken to the emergency room to be evaluated and returned to the community the same day. Based on interviews and a record review, R1’s responsible party received a call from the facility on October 13, 2024 alerting them of a medication error and that R1 was taken to the ER out of precaution. R1 was discharged back to the community the same day. Additionally, on October 17, 2024 the Department received an Special Incident Report (SIR) from the facility, related to the medication error and steps taken to ensure R1’s safety. Continued on 9099C... Substantiated Continued from 9099C... SIR also included that phone calls to R1’s responsible party were done to make them aware of the medication error. Based on the above, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 21-AS-20241106151738

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 18, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...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 was not met by licensee as evidenced by: R1 received another resident’s medication, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Facility to conduct an in-service training for all medication technicians on all shifts. Facility to provide to CCL a written plan to ensure all medication technicians are trained before the END of the November 2024. Copies of training material and roster of staff trained must be maintained on file for CCL review.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Wendy Cornejo, Administrator. Facility currently has nine [9] residents on hospice which is allowable per the facility's Hospice Waiver. Facility contact information was reviewed. At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA and Admin observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Cleaning supplies not stored with food items. Water temperature in sink(s) accessible to residents in care measured at 106 degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 11/21/2023. Smoke/Carbon Monoxide detectors and sprinklers located throughout the facility were tested and operational, last inspected 2/5/2024. Elevator permits expired 11/29/2023; however, annual inspection by State of CA, Dept of Industrial Relations is scheduled, LPA verified via email correspondence. Stairwells has evacuation chairs present. Facility’s last quarterly disaster drill was conducted on 2/7/2024. Facility has a backup generator for use during a power outage. At approximately 11:00am LPA conducted a review of five [5] resident records. All required documents present. Four [4] of out of the five [5] residents reviewed are on hospice; respective hospice care plans present. At approximately 2:00pm LPA conducted review five [5] staff files. All required documents present, required training completed. At approximately 12:30pm LPA conducted a spot check of medication and medication records. Medication is centrally stored in Medication carts which are stored in locked Medication room, refrigerator present for refrigerated medications. Report continued on LIC 809-C... Continued from 809... Wendy Cornejo Administrator Certificate 6018066740 expires 7/22/24. All fees are current as of this time. LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster Plan. No updates needed. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Evidence of Liability Insurance No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Feb 20, 2024