Inspection Reports for
Cogir of Folsom Memory Care

The complaint was substantiated regarding neglect and lack of supervision leading to a resident being pushed and sustaining fractures. The investigation found that the facility did not have enough staff scheduled based on residents' care needs at the time of the incident. An immediate civil penalty of $500 was assessed, with an additional penalty under review.

The investigation substantiated the allegation that a resident was pushed by another resident resulting in serious injury and cited a deficiency for insufficient staffing to provide adequate care and supervision. Other allegations regarding meal attendance, showering, and room cleanliness were unsubstantiated with no deficiencies cited.

The complaint investigation was substantiated for the allegation that staff did not update the resident's medical records, leading to the resident being sent to the wrong medical facility. The allegation of inadequate supervision resulting in a resident fall was unsubstantiated. The allegations that staff did not seek medical attention and did not notify the resident's responsible party were unfounded.

The investigation substantiated the allegation that staff did not update a resident's medical records, resulting in the resident being sent to the wrong medical facility. The allegation of inadequate supervision resulting in a resident fall was unsubstantiated. The allegations that staff did not seek medical attention and did not notify the resident's responsible party were unfounded. The facility's AC/heater wall unit was found to be in good condition and not a danger to residents. A deficiency was cited for failure to update resident medical records with correct emergency physician information.

The complaint investigation was substantiated for the allegation that staff did not update the resident's medical records. The allegation regarding inadequate supervision resulting in a resident fall was unsubstantiated. The allegations that staff did not seek medical attention and did not notify the resident's responsible party were unfounded. The allegation about the facility's AC/Heater wall unit being in disrepair was also unfounded.

The investigation substantiated the allegation that staff did not update a resident's medical records, resulting in the resident being sent to the wrong medical facility. The allegation of inadequate supervision resulting in a resident fall was unsubstantiated. The allegations that staff did not seek medical attention and did not notify the resident's responsible party were unfounded. The complaint about the facility's AC/Heater wall unit being in disrepair was unfounded as the unit was found to be in good condition.

The complaint investigation substantiated that due to facility staff's lack of care and supervision, a resident sustained serious bodily injury and another resident died. An immediate civil penalty of $500 was issued on December 23, 2024, and an additional civil penalty of $14,500 was issued on August 19, 2025.

The Department substantiated allegations that facility staff's inadequate supervision led to serious bodily injury and the death of a resident. A civil penalty was issued due to these violations.

The visit was complaint-related, continuing an investigation into staff working without a criminal record exemption and a medication error affecting resident R1. The complaint was substantiated as deficiencies were cited.

The investigation found that staff member S1 worked without a criminal record exemption since September 2024 and was removed from the schedule until exemption is granted. Additionally, a medication error was identified where resident R1 missed routine medications for approximately 30 days due to lack of an active primary care physician on file and delayed resolution by the Executive Director.

The complaint investigation substantiated allegations that due to facility staff's lack of care and supervision, a resident sustained serious bodily injury and another resident died. An immediate civil penalty of $500 was issued on December 23, 2024, and an additional civil penalty of $14,500 was issued on August 19, 2025.

The Department substantiated that facility staff's inadequate supervision resulted in a fatal altercation between residents, leading to a resident's death. A civil penalty was issued for violations of California Code of Regulations Title 22, § 87468.2(a)(4) concerning Personal Rights of Residents.

The visit was complaint-related, continuing an investigation into staff working without criminal record exemption and medication errors affecting a resident. The complaint was substantiated with deficiencies cited.

The investigation found that a staff member worked without a required criminal record exemption since September 2024 and was only removed from the schedule after discovery. Additionally, a resident missed approximately 30 days of routine medications due to unresolved issues with medication refills and lack of an active primary care physician on file.

The complaint was substantiated based on evidence that staff did not have required criminal clearance and that medication was not administered as prescribed. The substantiation means the allegations were valid based on the preponderance of evidence.

The investigation substantiated that a staff member worked without the required criminal record exemption, violating personnel requirements, and that a resident was not administered a prescribed medication dose, confirming medication mismanagement.

The complaint was substantiated based on evidence that staff were not qualified as required and medication mismanagement occurred. The substantiation means the allegations were valid based on the preponderance of evidence.

The investigation substantiated the allegations that a staff member (S1) worked without a required criminal record exemption and that a resident (R1) was not administered a prescribed medication dose on August 3, 2025, confirmed by medication audit and file review.

The complaint was substantiated. Staff neglect during a fire drill led to a resident being missing and subsequently hospitalized for heat exposure, dehydration, and acute kidney injury. An immediate civil penalty of $500 was assessed, with potential for additional penalties upon further review.

The investigation substantiated the allegation that staff neglected a resident who was lost during a fire drill, resulting in the resident being found outside with heat exposure, dehydration, and acute kidney injury. An immediate civil penalty of $500 was assessed due to the injury caused by staff neglect.

The inspection found that approximately 17 incident reports were submitted late, exceeding the seven-day reporting requirement, posing a potential risk to residents. Deficiencies were cited related to reporting requirements.

The visit was triggered by a complaint incident report received on August 7, 2025, regarding a medication error for a resident (R1) who missed medications for over 30 days due to no active primary care physician. The medication error was substantiated and has been resolved.

The investigation found that the medication error was not addressed promptly until the Regional Director of Health and Wellness was informed. The issue has since been resolved with the resident now having a primary care physician who prescribed the necessary medication refills. Deficiencies were cited related to this incident.

The complaint was substantiated. The allegation was that staff neglect resulted in resident dehydration and hospitalization. An immediate civil penalty of $500 was assessed for the injury due to staff neglect. The civil penalty assessment is under review and may be increased upon follow-up.

The investigation substantiated the allegation that staff neglect led to a resident (R1) being lost during a fire drill, resulting in heat exposure, dehydration, acute kidney injury, and hospitalization. Staff failed to conduct a required head count after the fire drill, allowing the resident to escape unnoticed for hours, posing an immediate health and safety risk.

The visit was complaint-related, triggered by multiple incident reports involving resident aggression, transport for evaluation, inappropriate resident behavior, and incidents causing physical altercations among residents. The reports were submitted late, violating reporting requirements.

The inspection found that the licensee failed to comply with reporting requirements, as approximately 17 incident reports were submitted late, exceeding the seven-day timeframe, posing a potential risk to residents in care.

The complaint was substantiated as the incident report revealed a medication error where resident R1 missed all medications for over 30 days due to no active primary care physician. The issue was addressed and resolved during the investigation.

The inspection found that the facility failed to ensure the resident received medications for more than 30 days, posing an immediate health and safety risk. The issue was resolved after the resident obtained a primary care physician who prescribed medication refills. Deficiencies were cited related to this medication error.

The complaint investigation was substantiated for the allegation that a resident was not receiving medication as prescribed. The allegation that a resident died due to neglect was unfounded. Allegations that staff dropped a resident during transfer and falsified resident records were unsubstantiated.

The investigation substantiated the allegation that a resident did not receive medication as prescribed, posing a potential health and safety risk. The allegation that a resident died due to neglect was found to be unfounded. Allegations that staff dropped a resident during transfer and falsified resident records were unsubstantiated due to lack of sufficient evidence.

The complaint was substantiated. Allegations included lack of care and supervision leading to serious bodily injury and death of residents. The investigation found staff failed to intervene during an altercation between residents, violating facility protocols. An immediate civil penalty of $500 was assessed.

The investigation substantiated that staff failed to follow facility protocols during an altercation between residents, resulting in one resident sustaining severe injuries and subsequent death. Staff did not intervene or redirect as required, posing an immediate health and safety risk.

The complaint was substantiated based on evidence that facility staff served expired food to residents. The allegation was validated by a preponderance of the evidence standard.

The investigation substantiated the allegation after a kitchen inspection revealed expired food items, including Hollandaise Sauce Mix and peanut butter, in the facility's dry pantry storage. The Executive Director confirmed the presence of expired salad dressing, which was properly disposed of prior to the inspection.

The complaint was substantiated based on evidence including expired food items found during inspection and file review. The allegation was that facility staff served expired food to residents.

The investigation substantiated the allegation after a kitchen inspection revealed expired food items including Hollandaise Sauce Mix and peanut butter in the pantry, posing a potential health and safety risk to residents.

The complaint was substantiated based on interviews and investigation. S1's actions violated residents' personal rights, and corrective actions including suspension and notification to licensing and ombudsman were taken.

The investigation confirmed that staff member S1 threatened resident R1 to stop using the call light, causing fear in the resident. S1 was suspended and is no longer employed at the facility. The facility notified appropriate authorities and parties about the incident.

The complaint was substantiated as the investigation confirmed the incident where staff member S1 threatened resident R1, violating personal rights and causing fear.

The investigation confirmed that staff member S1 threatened resident R1 to stop using the call light, causing fear in the resident. S1 was suspended and is no longer employed at the facility. The facility notified appropriate authorities and parties about the incident.