Inspection Reports for Cogir of Brea
700 Madison Way, Brea, CA 92821, United States, CA, 92821
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, some substantiated issues involved staffing shortages affecting resident care and food service quality, as well as medication mismanagement including delayed destruction of narcotics. The facility was cited for failure to provide adequate supervision to a resident who sustained multiple injuries from falls, resulting in immediate civil penalties. The most recent report from September 25, 2025, had no deficiencies and found allegations of staff under the influence and cleanliness concerns to be unsubstantiated. While there have been some serious findings in the past, recent inspections suggest improvement in compliance and resident care.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 74
Capacity: 110
Deficiencies: 0
Sep 25, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff were under the influence of alcohol while caring for and supervising residents.
Findings
The investigation included interviews with residents and staff, a health and safety check, and a review of staff files and facility policies. Four residents denied observing staff under the influence, while two staff confirmed the allegation. However, there was insufficient evidence to prove the allegation, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged staff were under the influence of alcohol while caring and supervising residents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Number of residents interviewed: 4
Number of staff interviewed: 10
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cynthia Figueroa | Executive Director | Met with investigator and discussed facility policies |
| Samuel Faye | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 110
Deficiencies: 0
Sep 25, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint received regarding facility cleanliness, kitchen appliance mold, food storage and cooking practices, and pest control.
Findings
The investigation found all allegations to be unfounded based on staff and resident interviews, observations of kitchen sanitation, food storage, cooking practices, and pest control measures. No evidence supported the complaints.
Complaint Details
The complaint alleged that staff did not ensure the facility was clean and sanitized, kitchen appliances were free of mold, food was properly stored and cooked, and the facility was free of pests. The allegations were found to be unfounded.
Report Facts
Capacity: 110
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analyst during investigation |
| Samuel Faye | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 110
Deficiencies: 2
Aug 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not ensure the resident's emergency pull button and outlets were properly operating and that staff mishandled a resident's medication.
Findings
The investigation substantiated that staff failed to ensure the resident's emergency pull button and outlets were properly operating, and that staff mishandled a resident's medication by leaving multiple medication patches on the resident contrary to physician orders. Deficiencies were cited under Title 22 Division 6 of the California Code of Regulations.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to ensure the resident's emergency pull button and outlets were properly operating and mishandling of a resident's medication. The medication mishandling involved multiple medication patches being left on the resident contrary to physician orders. The Plan of Correction included staff training on medication storage and destruction.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident call button was not in working order which poses an immediate health and safety risk to persons in care. | Type A |
| Resident outlets were not in working order. This poses an immediate health and safety risk to persons in care. | Type A |
Report Facts
Facility capacity: 110
Census: 69
Plan of Correction due date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cynthia Figueroa | Executive Director | Facility representative met during investigation and exit interview |
| Samuel Faye | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 110
Deficiencies: 1
Aug 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff did not properly maintain a resident's bathroom while in care.
Findings
The investigation found evidence of feces and urine traces in Resident #1's bathroom, but due to insufficient evidence to prove or disprove the allegation, the complaint was deemed unsubstantiated. A Technical Violation was issued.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence, despite observations and reports of bathroom cleanliness issues related to Resident #1's frequent urination and bowel movements.
Deficiencies (1)
| Description |
|---|
| Staff did not properly maintain a resident's bathroom while in care, with traces of feces and urine observed on the toilet and bathroom floor. |
Report Facts
Capacity: 110
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Samuel Faye | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 110
Deficiencies: 0
Aug 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations regarding resident care and staff performance at the facility.
Findings
All allegations including failure to meet a resident's incontinence needs, lack of planned activities, mishandling of personal belongings, unexplained injury, improper incident reporting, inadequate feeding, and insufficient record keeping were found to be unsubstantiated after review of records, interviews, and observations.
Complaint Details
The complaint investigation was triggered by allegations including unmet incontinence needs, lack of planned activities, mishandling of personal belongings, unexplained injury, improper incident reporting, inadequate feeding, and inadequate record keeping. After thorough investigation, all allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 110
Resident census: 70
Weight loss: 8
Number of staff interviewed: 6
Number of activities staff interviewed: 2
Number of residents interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Cynthia Figueroa | Executive Director | Facility representative met during investigation and exit interview |
| Samuel Faye | Administrator | Facility administrator listed in report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 110
Deficiencies: 0
Aug 6, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that residents were getting sick due to staff not cooking food thoroughly.
Findings
The investigation included interviews with residents and staff, observation of food preparation procedures, and a kitchen tour. All interviewed residents denied the allegation, and staff confirmed proper cooking procedures were followed. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that residents were getting sick due to staff not cooking food thoroughly. The allegation was found to be unsubstantiated after interviews and observations.
Report Facts
Capacity: 110
Census: 70
Complaint Control Number: 22-AS-20240625101021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Samuel Faye | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 110
Deficiencies: 0
Aug 6, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including rough handling of residents by staff, inadequate food service, inappropriate staff attendance at a resident council meeting, and lack of activities for residents.
Findings
Based on observations, record review, and interviews with residents and staff, there was insufficient evidence to substantiate the allegations. The investigation concluded that the allegations of rough handling, inadequate food service, inappropriate staff attendance at the resident council meeting, and lack of activities were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff handling residents roughly, inadequate food service, inappropriate staff attendance at a resident council meeting, and lack of activities for residents. Interviews with residents, staff, and former Executive Director, as well as observations, did not provide a preponderance of evidence to prove the allegations.
Report Facts
Capacity: 110
Census: 70
Number of residents interviewed: 3
Number of staff interviewed: 6
Number of activities scheduled daily: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analyst during investigation and participated in exit interview |
| Samuel Faye | Administrator | Facility administrator listed in report |
| Kara Kneedy-Cayem | Former Executive Director | Interviewed regarding staff attendance at resident council meeting |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 110
Deficiencies: 0
Jul 31, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2024-10-11 regarding safety, dietary order compliance, alcohol service, personal information safeguarding, climate control, admission of residents requiring higher care, and transportation services.
Findings
The investigation found all allegations to be unsubstantiated after reviewing resident files, interviewing staff and residents, and inspecting the facility. No preponderance of evidence was found to prove violations regarding safety, dietary orders, alcohol service, personal information safeguarding, climate control, admission practices, or transportation services.
Complaint Details
The complaint included nine allegations: failure to provide a safe environment, not following dietary orders, serving alcohol to residents with dementia, failure to safeguard personal information, non-operational climate control, admitting residents requiring higher care, and failure to provide transportation services as agreed. All allegations were found unsubstantiated based on interviews, document reviews, and observations.
Report Facts
Resident interviews: 4
Staff interviews: 13
Resident files reviewed: 7
Temperature range: 72.3
Temperature range: 74.1
Residents present at dinner: 40
Residents allowed alcohol: 2
Staff interviewed denying personal information breach: 9
Residents interviewed denying personal information breach: 3
Residents interviewed reporting partial refund: 1
Staff interviewed regarding transportation: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Samuel Faye | Administrator | Facility administrator named in report header |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 110
Deficiencies: 1
Jul 31, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-10-11 regarding insufficient staffing and food service issues at the facility.
Findings
The investigation substantiated three allegations: insufficient facility staff to provide care and supervision to memory care residents, insufficient kitchen staff to provide meal services, and food service being insufficient in both quantity and quality. These findings were based on staff and resident interviews, document reviews, and observations.
Complaint Details
The complaint investigation was substantiated. Allegations included insufficient facility staff for memory care residents, insufficient kitchen staff for meal services, and inadequate food service in quantity and quality. The substantiation was based on interviews with staff and residents, document reviews, and observations. The complaint control number is 22-AS-20241011144206.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet General Food Service Requirements including providing meals with appropriate variety, considering cultural and religious backgrounds, and ensuring food accessibility and quality. | Type B |
Report Facts
Capacity: 110
Census: 70
Deficiency Type: 1
Plan of Correction Due Date: Aug 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation report |
| Cynthia Figueroa | Executive Director | Facility representative met during the investigation and exit interview |
| Samuel Faye | Administrator | Facility administrator listed in the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 110
Deficiencies: 0
Jul 22, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility left a resident unattended for an extended period of time and did not provide care and supervision resulting in multiple falls.
Findings
The investigation found that Resident #1 is independent and only requires assistance with medication. The resident had an unwitnessed fall on July 19, 2025, but there was no evidence that the resident was left unattended for an extended period or that multiple falls occurred. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated. The allegations included the facility leaving a resident unattended for an extended period and failure to provide care and supervision resulting in multiple falls. The investigation included interviews with staff and review of resident records and incident reports.
Report Facts
Capacity: 110
Census: 62
Date of fall incident: Jul 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation |
| Cynthia Figueroa | Executive Director | Interviewed during the investigation and participated in exit interview |
| Samuel Faye | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 54
Capacity: 110
Deficiencies: 0
Jun 30, 2025
Visit Reason
Licensing Program Analyst Rose Ruppert made an unannounced visit to amend a report from a complaint visit on June 18, 2025.
Findings
The Licensing Program Analyst amended the resident identifier from R3 to R6 to match the correct resident from the Confidential List of Names provided on June 18, 2025. An exit interview was conducted with the Executive Director and a copy of the amended report was provided to the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced visit to amend the report. |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analyst during the visit and exit interview. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 110
Deficiencies: 1
Jun 18, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were mismanaging residents' medications, specifically regarding narcotics not being destroyed in a timely manner and improper storage of bubble packed medications.
Findings
The investigation found that narcotics from a deceased resident were not destroyed promptly as required by facility protocol, with medications discovered over a month after the resident's passing. Bubble packed medications were generally stored properly. The Memory Care Director was placed on leave and subsequently terminated related to the undestroyed medications incident. The allegation of medication mismanagement was substantiated.
Complaint Details
The complaint alleged staff were mismanaging residents' medications due to narcotics not being destroyed timely and improper storage of bubble packed medications. The complaint was substantiated based on evidence including interviews, record reviews, and surveillance footage.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: Prescription medications which are not taken with the resident upon termination of services shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years. This requirement was not met as medications were not destroyed until over a month after resident's passing and no signed record was found, posing a potential health and safety risk. | Type B |
Report Facts
Census: 54
Total Capacity: 110
Deficiency Plan of Correction Due Date: Jul 3, 2025
Resident Passing Date: Mar 24, 2025
Medication Destruction Date: May 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Cynthia Figueroa | Executive Director | Met with LPAs during investigation and exit interview |
| Dyan Summerell | Executive Director | Discovered undestroyed narcotics from deceased resident |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 110
Deficiencies: 0
Jun 18, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not following infectious protocols, not meeting residents' showering needs, falsifying residents' LIC 602 forms, and not providing a comfortable environment.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff followed infection control protocols, residents' showering needs were met or residents were independent, LIC 602 changes were appropriate or denied as improper, and staff and residents denied being told to hide information or not speak to licensing.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to follow infectious protocols, failure to meet showering needs, falsification of LIC 602 forms, and failure to provide a comfortable environment. Interviews with staff, residents, and review of documentation did not support the allegations.
Report Facts
Capacity: 110
Census: 54
Complaint Control Number: 22-AS-20250416144122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Hanna Gough | Licensing Program Analyst | Conducted the complaint investigation |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analysts during investigation |
| Samuel Faye | Administrator | Facility administrator listed in report |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 54
Capacity: 110
Deficiencies: 0
Jun 18, 2025
Visit Reason
The inspection was a required annual unannounced visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with no citations noted. Observations included a clean kitchen, proper storage of medications and chemicals, operational safety features, and accurate resident and staff records. A technical advisory was given during the inspection.
Report Facts
Capacity: 110
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analysts during inspection and participated in exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the inspection and signed the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 110
Deficiencies: 0
Jun 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-09 regarding improper resident appraisals for memory care placement and staff lacking job training or experience.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred. The allegations that staff did not conduct proper appraisals for memory care placement and that staff lacked job training or experience were determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not conduct proper appraisals to place residents in memory care and that staff did not have job training or experience in their assigned jobs. The investigation included review of resident assessments, staff and resident interviews, and training records. The findings concluded the allegations were unsubstantiated.
Report Facts
Capacity: 110
Census: 51
Complaint Control Number: 22-AS-20250509094345
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation visit |
| Erin Hernandez | Community Relations Director | Met with during the investigation and exit interview |
| Samuel Faye | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Cynthia Figueroa | Executive Director | Facility Executive Director involved in interviews and exit process |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 110
Deficiencies: 0
May 28, 2025
Visit Reason
The visit was an unannounced case management follow-up on a Death Report received on May 22, 2025, concerning Resident #1 (R1).
Findings
Based on file review, interviews, and observations, the facility was found to be in compliance with Title 22 California Code of Regulations, and no deficiencies were cited during this visit.
Complaint Details
The complaint involved a death incident where there was confusion regarding Resident #1's POLST form indicating both Do Not Resuscitate (DNR) and Full Treatment. The police department initiated CPR based on the Full Treatment box, but paramedics and the Power of Attorney confirmed the resident was DNR. The Fire Department will provide an in-service for facility staff regarding communication with first responders.
Report Facts
Facility capacity: 110
Resident census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit |
| Cynthia Figueroa | Executive Director | Met with Licensing Program Analyst and involved in incident discussion |
| Samuel Faye | Administrator/Director | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 110
Deficiencies: 1
May 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility is understaffed to provide services necessary to meet resident needs.
Findings
The investigation found that the facility was indeed understaffed during the visit, with observations and interviews confirming insufficient staffing to meet resident needs, posing an immediate health and safety risk.
Complaint Details
The complaint alleging understaffing was substantiated based on observations and interviews conducted during the unannounced visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements - General: Facility personnel were not sufficient in numbers and competence to provide necessary services to meet resident needs, posing an immediate health and safety risk. | Type A |
Report Facts
Census: 52
Total Capacity: 110
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Whitney Blake | Regional Vice President of Operations | Met with the Licensing Program Analyst during the investigation and participated in the exit interview |
| Samuel Faye | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 110
Deficiencies: 0
Mar 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-01-15 regarding resident and staff file documentation, staff criminal record clearance, staff qualifications, response times to residents' calls for assistance, and adequacy of food service.
Findings
The investigation found that resident and staff files contained all required documentation, staff had criminal record clearances and required qualifications, and the food service was adequate with sufficient quality and quantity. Response times to residents' calls ranged from 50 seconds to an average of 16 minutes 28 seconds. Overall, there was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove or refute the alleged violations. Allegations included missing documentation in resident and staff files, lack of criminal record clearance and qualifications for staff, delayed response to resident calls, and inadequate food service.
Report Facts
Census: 45
Total Capacity: 110
Response Time Range: 2
Response Time Range: 15
Average Response Time: 16.47
Staff and Resident File Review Percentage: 10
Resident Interview Count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
| Phil Altman | SVP of Operations | Facility representative who met with the Licensing Program Analyst during the investigation |
| Samuel Faye | Administrator | Facility administrator named in the report header |
| Executive Chef | Interviewed regarding food delivery and menu options |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 110
Deficiencies: 1
Mar 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff did not provide adequate supervision, resulting in a resident sustaining multiple injuries.
Findings
The investigation substantiated that staff failed to provide adequate supervision to Resident 1 (R1), who sustained multiple injuries from falls between April 3 and April 30, 2024. Despite interventions, the facility did not have a documented fall prevention plan and retained R1 knowing they could not meet R1's supervision needs. Immediate civil penalties were assessed.
Complaint Details
The complaint alleged that staff did not provide adequate supervision, resulting in a resident sustaining multiple injuries. The allegation was substantiated based on interviews, record reviews, and observations. The resident had multiple falls, some resulting in hospitalizations. The facility failed to implement an effective fall prevention plan and did not consult the resident's primary care or hospice providers regarding care needs.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services shall at a minimum include: (1) Care and supervision. The licensee did not ensure R1 received care and supervision, resulting in multiple injuries from falls on April 25, 2024 and April 29, 2024, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 110
Census: 45
Falls: 5
Civil Penalty: Immediate civil penalties assessed; amount pending
Plan of Correction Due Date: Due date for correction of deficiency is 03/21/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation report |
| Phil Altman | Senior Vice President of Operations | Met with investigator during the complaint investigation |
| Lakeisha Phillips | Regional Director of Health and Wellness | Met with investigator and provided information during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 110
Deficiencies: 1
Mar 20, 2025
Visit Reason
The inspection was an unannounced case management visit conducted during the investigation of complaint 22-AS-20240502115044 regarding unreported resident falls.
Findings
The facility failed to report several falls of Resident 1 that occurred on April 3, 5, and 30, 2024, to the Agency as required by California regulations, resulting in a citation.
Complaint Details
Investigation of complaint 22-AS-20240502115044 revealed unreported falls of Resident 1; the facility was cited for failure to report these incidents as required.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to report the falls of Resident 1 on April 3, 5, and 30 to the Agency, which poses a potential health and safety risk to residents in care. | Type B |
Report Facts
Falls reported: 2
Falls not reported: 3
Capacity: 110
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Phil Altman | Senior Vice President of Operations | Met with Licensing Program Analyst during the visit. |
| Sheila Santos | Licensing Program Manager | Supervisor and Licensing Evaluator named in the report. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 110
Deficiencies: 0
Feb 10, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-01-31 alleging the facility was not in good repair and was understaffed.
Findings
The investigation found that one of the two elevators was non-operational for two weeks due to a noise issue but was repaired on 2025-02-07. Staffing levels were reviewed and interviews with residents indicated that their needs were met and staffing was adequate. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged the facility was not in good repair and was understaffed. The investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.
Report Facts
Staff members on AM shift: 5
Staff members on PM shift: 4
Staff members on Night shift: 2
Residents interviewed: 4
Elevators in facility: 2
Days elevator was non-operational: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| Kara Kneedy-Cayem | Executive Director | Facility representative interviewed during investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 110
Deficiencies: 0
Jan 22, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations received on 2024-10-23 regarding safeguarding of resident's personal belongings, presence of surveillance cameras in resident rooms, and facility repair status.
Findings
The investigation found all three allegations to be unsubstantiated. Theft and loss incidents were logged and reported to law enforcement with no further action. Surveillance cameras were confirmed only in common areas with resident consent, and no cameras were found in resident rooms without approval. The facility was found to be in good repair with no outstanding maintenance issues.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to safeguard resident belongings, unauthorized surveillance cameras in resident rooms, and poor facility repair. Evidence did not support these allegations sufficiently to prove violations.
Report Facts
Facility capacity: 110
Resident census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kara Kneedy-Cayem | Executive Director | Facility representative who assisted during the investigation |
| Denise Renella | Marketing Director | Facility staff present during the investigation |
| Samuel Faye | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Oversaw the licensing program related to this investigation |
Inspection Report
Annual Inspection
Census: 45
Capacity: 110
Deficiencies: 1
Jul 22, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to assess compliance with regulations.
Findings
The facility was generally found to be in compliance with regulations including cleanliness, safety equipment, and resident room conditions. However, a deficiency was cited for one staff member not completing the required 20 hours of initial training within the first four weeks of employment.
Deficiencies (1)
| Description |
|---|
| Staff 1 did not complete the required 20 hours of training within the first four weeks of employment, including six hours specific to dementia care. |
Report Facts
Capacity: 110
Census: 45
Rooms inspected: 6
Resident files reviewed: 6
Staff files reviewed: 5
POC Due Date: Aug 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Im | Health Services Director | Met with Licensing Program Analyst during inspection and toured facility |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and authored the report |
| Samuel Faye | Administrator/Director | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 110
Deficiencies: 1
May 2, 2024
Visit Reason
The visit was an unannounced case management visit to begin the investigation into complaint #22-AS-20240502115044.
Findings
The Licensing Program Analyst observed that the required See Something, Say Something poster (PUB 475) was not posted in the main entry way of the facility but was instead posted in the hallway adjacent to the main entry way. The Health and Wellness Director was informed and acknowledged the requirement to post the poster in the main entry way.
Complaint Details
The visit was conducted as part of the investigation into complaint #22-AS-20240502115044. The complaint was related to the improper posting location of the PUB 475 poster.
Deficiencies (1)
| Description |
|---|
| See Something, Say Something poster (PUB 475) was not posted in the main entry way of the facility. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Im | Health and Wellness Director | Met with Licensing Program Analyst during the visit and acknowledged the poster posting requirement. |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 110
Deficiencies: 0
Jan 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-01-24 alleging inadequate feeding, unmet hygiene needs, and unsanitary client rooms at the facility.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and document review. None of the allegations were substantiated as resident and staff interviews, observations, and documentation did not corroborate the complaints. The facility was found to provide adequate feeding, hygiene assistance, and maintain clean and sanitary rooms.
Complaint Details
The complaint involved allegations that staff did not ensure clients were adequately fed, did not meet clients' hygiene needs, and did not keep clients' rooms clean or sanitary. The allegations were found to be unsubstantiated based on interviews, observations, and documentation.
Report Facts
Capacity: 110
Census: 26
Number of resident interviews: 4
Number of staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Charles Luetto | Community Relations Director | Met with during the investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Original Licensing
Capacity: 110
Deficiencies: 0
Jun 23, 2023
Visit Reason
The visit was an announced pre-licensing inspection conducted to evaluate the facility's readiness for initial licensing as a Residential Care Facility for the Elderly (RCFE) with a capacity of 110 non-ambulatory residents.
Findings
The facility was found to be a brand new apartment-style assisted living and memory care facility with all required safety, hygiene, and operational features in place, including working call systems, emergency plans, adequate food supplies, and fire clearance approval. No residents were present during the visit.
Report Facts
Capacity: 110
Bedridden residents allowed: 12
Visit duration hours: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samuel Faye | Designated Administrator | Greeted Licensing Program Analyst and participated in facility tour |
| Lydia Martinez | Licensing Program Analyst | Conducted the pre-licensing inspection visit |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Original Licensing
Capacity: 110
Deficiencies: 0
May 31, 2023
Visit Reason
The visit was an initial licensing evaluation conducted via telephone interview to verify the applicant/administrator's identity and understanding of California Code Title 22 regulations for a Residential Care Facility for the Elderly.
Findings
The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restricted health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Signed documentation and photo ID were obtained.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samuel Faye | Administrator | Applicant/administrator participating in COMP II interview and verification. |
| Benoit Levesque | Participant in COMP II interview with applicant/administrator. | |
| Jude De La Concepcion | Licensing Program Manager | Named in report header. |
| Bethany Hunter | Licensing Program Analyst | Named in report header and confirmed understanding of applicant/administrator. |
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