Inspection Reports for Cadence Millbrae by Cogir

An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements and ensure the safety and well-being of residents.

The facility was found to be generally compliant with regulations, including safety measures, medication management, and cleanliness. No citations were issued, but updated forms were requested to be submitted by 09/03/2025.

An unannounced complaint investigation visit was conducted in response to allegations received on 2025-07-30 regarding pest control and adequacy of food service at the facility.

The investigation found the allegation of pest presence unsubstantiated as the facility was actively monitoring pest control and passed county food safety inspections. The allegation of inadequate food service was found unfounded, with no meals skipped during a temporary kitchen closure and adequate alternative food services provided.

The complaint investigation was unsubstantiated for pest control issues and unfounded for inadequate food service. The allegations were either not supported by evidence or found to be false.

An unannounced complaint investigation visit was conducted to investigate allegations received regarding staff overcharging a resident in care and failure to communicate timely with the resident's POA, as well as re-evaluation of a resident's care plan without the POA present.

The investigation found the overcharging was an error corrected by the facility and communication issues could not be substantiated. The allegation regarding re-evaluation of the care plan without the POA present was found unfounded as POA attendance is not required by regulation. Overall, the allegations were unsubstantiated or unfounded.

The complaint investigation was unsubstantiated for allegations of overcharging and communication delays, and unfounded for the allegation of re-evaluating the resident's care plan without the POA present.

An unannounced complaint investigation visit was conducted in response to an allegation that staff mishandled a resident's medication.

The investigation found that the facility failed to provide a prescribed medication to a resident during two separate periods in 2024 without a physician's order to discontinue. This was due to facility error, and the allegation was substantiated.

The complaint was substantiated based on interviews and documentation reviewed. The medication was not given as prescribed due to facility error.

The visit was an unannounced case management - incident inspection conducted in response to an SOC 341 report received on 2024-11-07.

The facility staff investigated the reported incident but could not identify the person described by the resident. No staff or male residents matched the description, and the facility lacks cameras in common areas. As a precaution, the facility implemented a plan to prevent males from entering the resident's room, including assigning no male staff to the resident unless accompanied by a female care partner. The family is aware and cooperating. No citations were issued.

An unannounced case management visit was conducted to request documentation related to a prior complaint investigation from 2023 regarding a resident's ADL reference sheet.

The facility was unable to provide the requested resident document dated 06/27/2023, which is required to be retained for three years. This failure poses a potential health and safety risk and resulted in a citation being issued.

The visit was related to complaint #14-AS-20230804102303. The facility was unable to provide the requested documentation related to the complaint, resulting in a citation.

An unannounced annual inspection visit was conducted to evaluate compliance with regulatory requirements for the assisted living and memory care facility.

The facility was found to be clean, safe, and well-maintained with proper medication storage and current staff and resident files. No citations were issued, and all safety equipment and emergency procedures were observed to be in place and current.

The visit was a non-compliance conference meeting conducted by the San Bruno Regional Office to discuss violations and ensure compliance with Title 22 Regulations.

During the meeting, multiple violations related to personal rights, infection control, reporting requirements, observation of residents, basic services, and reappraisals were discussed. The licensee will receive more frequent monitoring inspection visits for two years to ensure compliance.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were not providing medication as prescribed.

The investigation found inconsistent information regarding medication administration of Quetiapine in January 2024. Based on interviews and documentation, the allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation.

The complaint alleged that staff were not providing medication as prescribed. The investigation included review of client files, interviews with the client and staff, and examination of medication administration records. The allegation was found unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by an allegation of staff financially abusing a resident in care.

The investigation included interviews with residents and review of client records. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation did or did not occur. There was a related allegation of female staff 'flirting' with male residents to get cash tips, which may have occurred as an isolated incident but was not substantiated.

The complaint alleged staff were financially abusing a resident in care. The allegation was found unsubstantiated after investigation. It was also alleged that female staff were 'flirting' with male residents to get cash tips; this was neither proven nor refuted conclusively.

The inspection was an unannounced complaint investigation triggered by allegations that staff do not ensure residents are adequately fed and that the facility is charging for services not rendered.

The investigation found the allegations to be unsubstantiated and unfounded. Observations, interviews, and record reviews showed that meal services were provided as ordered, and residents reported satisfaction with meal delivery. Charges for meal delivery were confirmed with discounts applied.

The complaint alleging inadequate feeding of residents and charging for undelivered meal services was investigated and determined to be unsubstantiated and unfounded, respectively.

An unannounced complaint investigation visit was conducted in response to allegations that staff failed to meet a resident's needs and that a resident sustained multiple falls and injuries while in care.

The investigation found that the resident had multiple documented falls between March 2022 and May 2023, including a significant fall on May 29, 2023, which resulted in hospitalization and arm separation. The facility failed to reassess the resident as a fall risk and did not establish or update safety measures to prevent further falls.

The complaint was substantiated based on the preponderance of evidence. The resident sustained multiple falls, including a serious fall on May 29, 2023, with no staff supervision present at the time. The facility failed to reassess and update care plans to prevent falls.

Unannounced complaint investigation visit triggered by allegations that a resident sustained an arm separation and suffered from dehydration while in care.

The investigation substantiated the allegations, finding that the facility failed to provide adequate supervision to a fall-risk resident and failed to monitor and seek medical attention for changes in the resident's condition, resulting in injury and severe dehydration requiring hospitalization.

The complaint was substantiated based on review of facility and medical records and staff interviews. The resident was admitted to ICU with severe sepsis and hypernatremia after missed meals and inadequate documentation and monitoring by staff.

The visit was a Case Management - Deficiencies unannounced inspection to evaluate the facility's organizational changes and compliance with licensing requirements.

The facility was found deficient for failing to submit a new application for licensure following a change of ownership and management. Cogir Management USA Inc. acquired the facility but has not yet applied for RCFE licensure, posing a potential health, safety, or personal rights risk to clients.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/19/2022 regarding the facility not providing a comfortable temperature for residents and not adhering to the admissions agreement.

The investigation substantiated the allegations that the facility failed to maintain a comfortable temperature in residents' apartments during extreme heat and did not adhere to the admissions agreement which stated apartments were air conditioned. The residency agreements were subsequently revised to remove the air conditioning claim.

The complaint was substantiated based on observations during the initial visit on 09/22/2022, information from facility staff and the complainant, meeting with the business office manager and new executive director, and review of residency agreements.

The visit was a Case Management - Health Checks to discuss recent move-ins and review admission documentation compliance.

No health or safety deficiencies were observed during the visit. The administrator was reminded to ensure completion of required admission documents and to submit documentation for administrator designation.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was operating without an Administrator and that transportation vehicles were in disrepair.

The investigation found that the previous administrator's last working day was 9/21/22 and the vice president of operations has been acting as interim administrator. The facility's only vehicle, a Ford Starcraft bus, has not been driven for over 3 months due to the resignation of the Class B driver, and will be inspected before use. Despite expired registration stickers, vehicle registration was paid and proof provided. The complaint was determined to be unfounded.

The complaint was investigated and determined to be unfounded, meaning the allegations could not have happened and/or were without a reasonable basis.

The visit was conducted as a case management follow-up on a Suspected Abuse Report submitted to the Community Care Licensing Division on 9/12/22 regarding suspected financial abuse of a client.

No deficiencies were cited during this visit. The licensing program analyst obtained details of the incident, including law enforcement case number and sheriff contact information, but no additional information was provided as the incident was handled by a former executive director.

The visit was related to a suspected financial abuse complaint involving client #1. The complaint was investigated, but no deficiencies were cited. The incident was handled by the former executive director who is no longer employed.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-06-02 regarding concerns that a resident's needs were not being met, the resident was not being fed, and the resident's room was unkempt.

The investigation found the allegations to be unsubstantiated after reviewing the client's file, observing the client's room, and interviewing the client, staff, and witnesses. Staff provided assistance when needed, including during a COVID infection, and the food delivered was not eaten by the client.

The complaint was unsubstantiated based on the investigation findings. Although some concerns may have occurred or be valid, there was insufficient evidence to prove the alleged violations.

The visit was conducted as a case management incident related to a suspected abuse report submitted to the Community Care Licensing Division (CCLD).

The investigation is still pending and was handled by the former executive director who is no longer employed. Additional information is not available at this time. An updated Personnel Report (LIC500) is to be submitted to CCLD by 9/29/22.

Investigation of suspected abuse report is pending; handled by former executive director; additional information unavailable.

The visit was conducted in response to information about COVID infections among staff and clients at the facility, to assess compliance with infection control and reporting requirements.

The facility failed to report COVID cases to the Community Care Licensing Division and local public health department, lacked proper PPE supplies, did not maintain daily symptom and temperature logs for staff and clients, and did not follow proper isolation procedures for COVID-positive residents. Staff were observed not wearing full PPE when assisting COVID clients.

The visit was complaint-related due to reports of COVID infections among staff and clients. The complaint was substantiated as multiple deficiencies related to infection control and reporting were found.

The visit was an unannounced case management incident review related to a memory care client who left the building unattended on 03/13/22 and was found an hour later at his residence.

The staff were unable to determine how the resident exited the building given security measures in place. Physician's Report, updated Service Plans, and documentation of staff participation in an Elopement Drill were reviewed and submitted. No deficiencies were cited.

The visit was conducted in response to a capacity change application for 165 elderly residents, including touring a new memory care unit and evaluating its readiness.

The new memory care unit was found not ready to accommodate residents due to missing COVID signage, lack of liquid soap and paper towels in bathrooms, and concerns about the vestibule egress. Fire clearance and safety features were approved, but some hygiene and signage deficiencies were noted.

The inspection was a required unannounced 1-year visit to evaluate the facility's compliance with regulations and overall operations.

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 were cited. The facility is undergoing renovations and maintains adequate infection control practices, proper storage of medications and sharps, and sufficient PPE supply. Technical violations and advisories were issued.

The visit was a case management follow-up to investigate the circumstances of a client's death reported on 02/24/2021.

The investigation determined the client's death on 02/23/2021 was natural and not questionable, caused by heart failure. The client was independent and did not require care or supervision. No deficiencies were cited based on this incident.

Unannounced complaint investigation visit conducted in response to allegations that facility staff failed to give resident medication on time, restricted resident visitors, and restricted resident phone calls.

The investigation found no preponderance of evidence to substantiate the allegations. Medication was administered timely, visitor restrictions were due to COVID-19 safety policies, and residents had access to phones. Therefore, all allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated based on review of medical records, facility policies related to COVID-19 visitor restrictions, and resident phone access. Allegations included medication timing, visitor restrictions, and phone call restrictions.

Unannounced visit/investigation of a complaint received on 2020-06-09 regarding allegations of unlawful eviction and unexplained injuries.

The investigation found no preponderance of evidence to substantiate the allegations of unlawful eviction and unexplained injuries. The allegations were deemed unsubstantiated based on record reviews and interviews.

The complaint involved allegations of unlawful eviction and unexplained injuries. The investigation concluded these allegations were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-06-23 regarding inadequate lighting at the facility.

The investigation found that the facility's lighting, including emergency lighting in stairwells, complied with applicable codes from 1984 and 1982 fire codes. The facility has a backup generator for power outages and is undergoing renovations that would address lighting upgrades. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged the facility was without adequate lighting. The investigation included a virtual tour and interviews with the administrator and fire marshal. The complaint was deemed unsubstantiated.

An unannounced case management televisit was conducted regarding a Death Report submitted to the Community Care Licensing Office on 02/24/2021.

Resident R1 missed a routine dialysis appointment and was found unresponsive at the facility, with paramedics called to the scene. The Sheriff's Deputy investigating suspects the cause of death was a heart attack related to the resident's health conditions, and the coroner's office likely will not perform an autopsy. The facility is reaching out to the family and has secured the resident's room.