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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804032
Report Date: 08/28/2026
Date Signed: 08/28/2026 03:01:33 PM

Substantiated


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
06/10/2026 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20260610153456
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: 89DATE:
08/28/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Werndy Cornejo, Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
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
06/10/2026 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20260610153456

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: 89DATE:
08/28/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Werndy Cornejo, Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not follow doctor's orders, resulting in resident developing a pressure injury
Staff did not ensure resident's care needs were met
Staff did not repair faulty wire that sparked when moved
Facility did not issue a proper eviction to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegations. LPA met with Administrator Wendy Cornejo.

Complaint alleges staff did not follow doctor's orders, resulting in resident developing a pressure injury. Complainant states that R1 had severe edema and R1’s leg would rub against their wheelchair. Complainant alleges R1 developed bruises on legs that turned into wounds due to staff not following doctor’s orders for compression socks and to keep legs elevated. During investigation, LPA received documents showing Home Health care notes and suggestions for wraps/juxtalite and compression socks. Per review of Home Health records, wound care was provided by Home Health. During investigation, LPA reviewed doctor’s orders. LPA did not observe any doctor’s orders for wraps, socks, or cream. However, charting notes indicate staff elevated leg and were using compression socks. Additionally, LPA received copies of fax requests showing facility requesting and inquiring about a doctor’s order for leg care. Per staff interview and LPA record

Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
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-20260610153456
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: 08/28/2026
NARRATIVE
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20260610153456
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: 08/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2026
Section Cited
CCR
87465(a)(4)
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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
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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.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260610153456
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: 08/28/2026
NARRATIVE
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5