<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804032
Report Date: 05/28/2026
Date Signed: 05/28/2026 02:58:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2026 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20260311115010
FACILITY NAME:COGIR OF SONOMA PLAZAFACILITY NUMBER:
496804032
ADMINISTRATOR:CORNEJO, WENDYFACILITY TYPE:
740
ADDRESS:91 NAPA ROADTELEPHONE:
(707) 939-1500
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:105CENSUS: 95DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Wendy Cornejo, AdministratorTIME COMPLETED:
03:12 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly assessing residents for a higher level of care
Resident's care needs are not being met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2026 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20260311115010

FACILITY NAME:COGIR OF SONOMA PLAZAFACILITY NUMBER:
496804032
ADMINISTRATOR:CORNEJO, WENDYFACILITY TYPE:
740
ADDRESS:91 NAPA ROADTELEPHONE:
(707) 939-1500
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:105CENSUS: DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Wendy Cornejo, AdministratorTIME COMPLETED:
03:12 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights
Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Personal Rights. Complainant states staff (S1) is aggressive and hurts residents. Complainant states that S1 was abusive toward resident (R3). S1 grabbed R3 by the wrists and was aggressively forceful. Additionally, complainant states S1 was abusive to resident (R4), R4 experienced a suspicious fall while under S1’s direct supervision. During investigation, LPA conducted interviews. Per Admin, upon learning of S1’s aggressive behavior she interviewed staff and residents. Both staff and residents reported to Admin that S1 was aggressive and rough when providing care. Admin immediately issued corrective disciplinary action and conducted training with S1. S1 then subsequently resigned from their duties and quit. Based on LPA’s interview, 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260311115010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COGIR OF SONOMA PLAZA
FACILITY NUMBER: 496804032
VISIT DATE: 05/28/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20260311115010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COGIR OF SONOMA PLAZA
FACILITY NUMBER: 496804032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
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.
1
2
3
4
5
6
7
Facility held a meeting to discuss medication management and conducted training with all staff administering medication on 4/6/26. Deficiency cleared.
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14
Type B
05/29/2026
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
§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
1
2
3
4
5
6
7
Facility immediately issued corrective disciplinary action and conducted training with S1 on 3/11/26. Deficiency cleared
8
9
10
11
12
13
14
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 care
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260311115010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COGIR OF SONOMA PLAZA
FACILITY NUMBER: 496804032
VISIT DATE: 05/28/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5