Inspection Reports for Cogir of Turlock

The visit was a case management inspection focused on deficiencies related to the pendant call alert system and staff response times.

The facility's pendant call alert system was found to be unreliable, with documented response times exceeding acceptable limits and ongoing issues with alert clearing and staff notification. This posed an immediate risk to residents' health, safety, and personal rights, resulting in a Type A deficiency citation.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not ensure resident’s signaling equipment was maintained in operable condition.

The investigation found that notifications from resident signaling equipment were not heard or responded to by staff, specifically the Memory Care phone was not audible. The allegation was substantiated and a deficiency was cited for failure to maintain a signal system able to summon staff, posing an immediate health and safety risk.

The complaint was substantiated based on observations and interviews conducted by Licensing Program Analyst Renee Campbell. The specific allegation was that staff did not ensure resident’s signaling equipment was maintained in operable condition, which was confirmed during the investigation.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-01-23 alleging staff inappropriately solicited money from residents, staff not meeting residents' needs, and staff not ensuring enough supplies for residents.

The allegation that staff inappropriately solicited money from residents was substantiated, citing a deficiency related to solicitation conflicting with the facility's No Tipping policy. The allegations that staff were not meeting residents' needs and not ensuring enough supplies were unsubstantiated based on interviews with staff and residents.

The complaint investigation was substantiated for the allegation that staff inappropriately solicited money from residents. The allegations that staff were not meeting residents' needs and not ensuring enough supplies were unsubstantiated.

The inspection was an unannounced annual inspection conducted by Licensing Program Analyst Renee Campbell to evaluate compliance with licensing requirements.

The facility was observed to be clean, odor-free, and in good repair with appropriate furnishings and safe environmental conditions. However, four of seven resident files reviewed were missing tuberculosis (TB) tests or chest x-rays, resulting in a cited deficiency.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were inappropriately charging residents for food delivery.

The investigation found that clients were not charged for tray service when ill, consistent with the admission agreement, and residents confirmed they had not been charged improperly. The allegation was unsubstantiated and no deficiencies were cited.

The complaint alleged inappropriate charging of residents for food delivery. The allegation was unsubstantiated due to lack of preponderance of evidence.

An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations at the facility.

The facility was observed to be clean, odor-free, and in good repair with properly furnished bedrooms and adequate food supplies. No deficiencies or citations were issued during this visit.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-11-09 alleging staff mismanagement of residents' medication and other issues.

The investigation substantiated the allegation that staff mismanaged residents' medication, with evidence showing medication errors were corrected immediately but deficiencies were cited. Other allegations regarding notification of authorized representatives and confidentiality of personal information were unsubstantiated.

The complaint investigation was substantiated for the allegation that staff mismanaged residents' medication. Other allegations about failure to notify authorized representatives of level of care changes and failure to provide 60-day notice of rate increase were unsubstantiated. The allegation regarding confidentiality of personal information was also unsubstantiated.

The visit was an unannounced Case Management - Incident inspection triggered by an incident report received regarding a medication error that occurred on 02/07/2024.

The inspection found that a medication error occurred due to a MedTech dispensing medication incorrectly by not reading the medication orders or following dispensing procedures. The incident report was received late, 6 days past the 7-day reporting requirement. A deficiency was cited related to this incident.

The complaint was substantiated as the medication error was confirmed to have occurred on 02/07/2024 due to staff error. The incident report was received late, violating reporting requirements.

The inspection was an unannounced complaint investigation triggered by a complaint received on 2023-11-09 regarding staff not providing a resident's authorized representative with the resident's records.

The allegation was substantiated as the facility failed to provide requested resident records within the required two business days, with records only being fully provided in February 2024 after requests in October 2023, posing a potential health, safety, or personal rights risk.

The complaint was substantiated based on evidence that the resident's representative did not receive requested unredacted records until several months after the request, violating the two business day requirement.

An unannounced complaint investigation was conducted regarding an allegation that staff handled a resident in a rough manner.

The investigation found no preponderance of evidence to support the allegation after interviews with 6 staff and 4 residents. The allegation was deemed unsubstantiated and no deficiencies were cited.

The allegation that staff handled a resident in a rough manner was investigated and found unsubstantiated based on interviews and lack of evidence.

Licensing Program Analyst Jason Lund arrived unannounced to conduct an annual/required inspection and met with the Executive Director to explain the reason for the visit.

The facility was toured and inspected including activity areas, common areas, kitchen, memory care unit, and exterior grounds. All safety measures, food storage, and fire extinguishers were found to be in compliance. No deficiencies were observed during the visit.

Unannounced prelicensing visit conducted to evaluate the facility's readiness for licensing and compliance with regulations.

The facility was toured including resident rooms, common areas, kitchen, and safety equipment. All observed areas and safety measures were found to be in compliance with no deficiencies noted during the visit.

The visit was conducted as a change of ownership evaluation for the Residential Care Facility for the Elderly, including verification of applicant and administrator identification and understanding of California Code Title 22 regulations.

The applicant and administrator demonstrated understanding of licensing requirements, facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness during a telephone interview.