Inspection Reports for Cogir of Brentwood
150 Cortona Way, Brentwood, CA 94513, United States, CA, 94513
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent report from March 26, 2025, which was clean despite being prompted by a resident’s unwitnessed fall resulting in a broken hip. Earlier reports showed some issues, notably substantiated complaints in June 2023 about roach infestations and unsecured medications accessible to a resident with dementia, both of which posed health and safety concerns. Staff certification and personnel record deficiencies were noted in February 2024 but were not repeated in later inspections. Several complaint investigations were unsubstantiated, including allegations about pressure injuries, medication errors, and staffing shortages. The facility’s record shows improvement over time, with recent inspections consistently meeting regulatory standards.
Deficiencies per Year
4
3
2
1
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 127
Capacity: 150
Deficiencies: 0
Mar 26, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report involving a resident's unwitnessed fall.
Findings
The inspection found no deficiencies. The resident sustained a broken right hip from the fall and was hospitalized and later admitted to a skilled nursing facility. The resident was independent prior to the fall and has since returned to the community and is socially active.
Report Facts
Incident date: Mar 16, 2025
Incident report date: Mar 21, 2025
Resident admission date to skilled nursing: Mar 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Administrator/Director | Facility administrator named in report header |
| Cayia Peevy | Executive Director | Met with Licensing Program Analyst during visit |
| Kuldip Singh | Health and Wellness Director | Met with Licensing Program Analyst during visit |
| Tonica Syess-Gibson | Licensing Program Analyst | Conducted the case management visit |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 150
Deficiencies: 0
Mar 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident (R1) developed a stage 3 pressure injury while in care and that staff did not assist the resident with incontinence needs.
Findings
The investigation found that the resident's pressure injury was present prior to hospital admission and was treated effectively by home health services, with no evidence that facility staff contributed to the injury. Staff interviews and records indicated that the resident sometimes refused care but was generally assisted as needed. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated. Allegations included a stage 3 pressure injury and lack of assistance with incontinence needs. Interviews with staff, residents, family members, and home health nurse, as well as medical record reviews, did not support the allegations. No deficiencies were cited.
Report Facts
Facility capacity: 150
Census: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation |
| Cayia Henry | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 120
Capacity: 150
Deficiencies: 0
Feb 6, 2025
Visit Reason
The visit was an unannounced 1-Year Annual Required inspection to evaluate compliance with licensing regulations and facility conditions.
Findings
No deficiencies were observed during the visit. The facility was found to be in compliance with safety, environmental, and administrative requirements, including fire clearance, adequate lighting, temperature control, and complete staff and resident records.
Report Facts
Hospice waiver residents: 12
Fire clearance capacity: 150
Staff records reviewed: 5
Resident records reviewed: 5
Fire extinguisher last serviced: Jan 2, 2025
Fire drill last conducted: Jan 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Administrator | Named as facility administrator. |
| Cayia Peevy | Executive Director | Met with Licensing Program Analysts during inspection. |
| Tonica Syess-Gibson | Licensing Program Analyst | Conducted the inspection. |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager. |
Inspection Report
Census: 120
Capacity: 150
Deficiencies: 0
Oct 21, 2024
Visit Reason
The visit was an unannounced case management inspection conducted regarding an incident report received on 2024-10-16 involving a resident's fall.
Findings
The inspection found that Resident 1 had an unwitnessed fall resulting in a head laceration and fractured pelvis. Staff responded appropriately, and no deficiencies were cited during the visit.
Report Facts
Incident report date: Oct 16, 2024
Inspection start time: 1423
Inspection end time: 1610
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Administrator/Director | Facility administrator named in report header |
| Davina Barker | Regional Executive Director | Met with Licensing Program Analyst during inspection |
| Kuldip Singh | Health Wellness Director | Met with Licensing Program Analyst during inspection and involved in incident discussion |
| Tonica Syess-Gibson | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 110
Capacity: 150
Deficiencies: 2
Feb 20, 2024
Visit Reason
The inspection visit was an unannounced 1-Year Annual Required inspection to evaluate compliance with licensing regulations.
Findings
The facility was toured and found to maintain safe and comfortable conditions including adequate lighting, temperature, and safety equipment. However, deficiencies were observed related to staff certification and personnel records, specifically that the majority of staff were not first aid or CPR certified and several staff lacked health screening or TB test documentation.
Deficiencies (2)
| Description |
|---|
| Majority of staff were not first aid or CPR certified. |
| Several staff did not have a health screening or TB test on record. |
Report Facts
Facility census: 110
Facility capacity: 150
Fire clearance: 150
Hospice waiver: 12
Fire extinguisher last serviced: Jan 12, 2024
Fire drill last conducted: Feb 19, 2024
Staff records reviewed: 10
Resident records reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Executive Director | Met with Licensing Program Analysts during inspection and agreed to plans of correction |
| Laura Hall | Licensing Program Analyst | Conducted inspection and signed report |
| Harpreet Humpal | Licensing Program Manager | Supervised inspection and named in report |
Inspection Report
Census: 111
Capacity: 150
Deficiencies: 0
Dec 14, 2023
Visit Reason
An unannounced case management visit was conducted regarding a resident incident involving an unwitnessed fall that led to a fractured hip and subsequent surgery.
Findings
The resident was recovering in skilled nursing after hip surgery. No deficiencies were cited during the visit. The facility provided requested documentation and communicated with the resident's family.
Report Facts
Resident incident date: Dec 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kuldip Singh | Health and Wellness Director | Interviewed regarding resident incident and follow-up |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 150
Deficiencies: 1
Jun 21, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 2023-06-15 regarding the presence of roaches in the facility.
Findings
The allegation of roaches inside the facility was substantiated based on record review and interviews with staff and a resident's family member. The facility was found not to comply with cleanliness and maintenance regulations due to the presence of roaches, posing potential health and personal right risks.
Complaint Details
Complaint was substantiated. The complaint involved the presence of roaches inside the facility, confirmed by interviews and documentation. Pest control was hired to address the issue.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain clean, safe, sanitary, and in good repair conditions as evidenced by presence of roaches. | Type B |
Report Facts
Capacity: 150
Census: 84
Plan of Correction Due Date: Jul 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation |
| Jeffrey Freeth | Executive Director | Facility representative involved in investigation and discussion of findings |
| Sylvia Chue | Business Office Manager | Facility representative met during investigation |
| Bennett Fong | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 150
Deficiencies: 1
Jun 21, 2023
Visit Reason
The inspection was conducted unannounced as a result of receiving a priority 1 complaint regarding health and safety concerns at the facility.
Findings
The inspection found that medications, ointments, and cleaning supplies were accessible to a resident with dementia, which poses immediate risks. A deficiency was cited for failure to comply with regulations regarding storage of such items.
Complaint Details
The visit was triggered by a priority 1 complaint (Complaint # 15-AS-20230615163239).
Deficiencies (1)
| Description |
|---|
| Medications, ointments, and cleaning supplies were accessible to a resident with dementia, violating storage requirements. |
Report Facts
Hot water temperature: 117.3
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Executive Director | Met with Licensing Program Analyst during inspection and discussed deficiency |
| Alicia Delmundo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 150
Deficiencies: 0
May 8, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-02-15 alleging medication was not administered as ordered, residents were charged for services not provided, and insufficient staffing.
Findings
The investigation found that medication was administered according to physician orders, residents denied being charged for unprovided services, and staffing was sufficient across all shifts. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to administer medication as ordered, charging residents for services not provided, and insufficient staffing. Interviews and records review did not support these allegations.
Report Facts
Capacity: 150
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ibo | Licensing Program Analyst | Conducted the complaint investigation |
| Jeff Freeth | Executive Director | Met with Licensing Program Analyst during investigation |
| Kuldip Singh | Facility Nurse | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 150
Deficiencies: 0
Feb 2, 2023
Visit Reason
The visit was an unannounced case management inspection triggered by a self-reported incident involving missing jewelry reported by a resident on 2023-02-01.
Findings
The Licensing Program Analyst met with the Administrator and reviewed the incident report. The facility is conducting its own investigation and has filed a police report. The Licensing Program Analyst did not have access to all documents due to the ongoing investigation and plans to return once information is received.
Complaint Details
The incident involved a resident reporting missing jewelry taken from her apartment. The facility notified the resident's family and filed a police report. Investigation is pending.
Report Facts
Census: 93
Total Capacity: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Martino | Administrator | Met with Licensing Program Analyst during the visit and involved in incident reporting |
| Leslie Ibo | Licensing Program Analyst | Conducted the unannounced case management visit |
| Harpreet Humpal | Licensing Program Manager | Named in the report header |
Inspection Report
Original Licensing
Census: 95
Capacity: 150
Deficiencies: 0
Jan 17, 2023
Visit Reason
The inspection was conducted as a prelicensing visit due to a change of ownership at the facility.
Findings
No issues were noted during the inspection. The facility was found to be ready for licensing, with proper furniture, safety equipment, and environmental conditions observed throughout.
Report Facts
Room temperature: 76
Hot water temperature: 108.9
Fire extinguisher service date: Jan 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Martino | Executive Director | Met with Licensing Program Analysts during inspection |
| Carol Fowler | Licensing Program Analyst | Conducted the prelicensing inspection |
Inspection Report
Census: 95
Capacity: 150
Deficiencies: 0
Jan 17, 2023
Visit Reason
The visit was a Case Management - Other type, involving a face-to-face Component III presentation and discussion of regulations with the Executive Director.
Findings
LPAs conducted a presentation on regulations and observed that the participant gained knowledge about running and maintaining the facility in accordance with regulations. An exit interview was conducted with the Executive Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Martino | Executive Director | Met with LPAs during the Component III presentation and exit interview. |
Inspection Report
Original Licensing
Census: 51
Capacity: 150
Deficiencies: 0
Oct 20, 2022
Visit Reason
The visit was conducted as a Component II evaluation by the Community Care Licensing Division (CAB) to assess the applicant's and administrator's understanding of licensing requirements and facility operation for initial licensing.
Findings
The Component II evaluation was successfully completed via telephone, confirming the applicant and administrator's understanding of Title 22 regulations, facility operation, staff qualifications, program policies, and application document requirements.
Report Facts
Capacity: 150
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Martino | Administrator | Administrator and Applicant's Representative participating in the Component II evaluation |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Thai Doan | Licensing Program Analyst | Named as Licensing Program Analyst on the report |
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