Inspection Reports for Cogir of Turlock
3791 Crowell Rd, Turlock, CA 95382, United States, CA, 95382
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related to resident care and safety, particularly involving the pendant call alert system, medication management, and timely access to resident records. Several complaint investigations were substantiated, including issues with staff soliciting money from residents and failure to maintain operable signaling equipment, both posing risks to residents’ health and safety. The facility was cited for a Type A deficiency in its most recent report dated October 21, 2025, due to an unreliable call alert system that posed immediate risk. Earlier reports showed medication errors and delays in providing records, while some complaints about staff conduct and charging practices were unsubstantiated. There is no clear pattern of improvement or decline, but the most recent serious deficiency indicates ongoing challenges with communication and response systems.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Census: 74
Capacity: 100
Deficiencies: 1
Oct 21, 2025
Visit Reason
The visit was a case management inspection focused on deficiencies related to the pendant call alert system and staff response times.
Findings
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The pendant/call alert system has not been functioning properly since at least 09/01/2025, posing an immediate risk to the health, safety, and personal rights of residents. | Type A |
Report Facts
Percentage of pendant calls with response time longer than 15 minutes: 20
Percentage of pendant calls with response time longer than 30 minutes: 6
Census: 74
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lisa Rios | Licensing Program Manager | Named in relation to the licensing program and report |
| Andrea Eldridge | Memory Care Director | Met with Licensing Program Analyst during inspection and discussed pendant system issues |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 100
Deficiencies: 1
Jul 15, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a signal system that transmits a visual and/or auditory signal to summon staff as required by CCR 87303(i)(1)(B). | Type A |
Report Facts
Capacity: 100
Census: 78
Deficiency Type: 1
Plan of Correction Due Date: Jul 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the complaint investigation and made observations regarding signaling equipment |
| Jackie Hernandez | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 100
Deficiencies: 1
Jun 26, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to maintain a current definitive plan of operation for the facility, specifically regarding solicitation of donations conflicting with the No Tipping policy. | Type B |
Report Facts
Capacity: 100
Census: 76
Deficiencies cited: 1
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the complaint investigation and presented findings |
| Jackie Hernandez | Executive Director | Met with Licensing Program Analyst during investigation and provided statements regarding solicitation and facility policies |
| Janet Johns | Administrator | Named as facility administrator |
| Lisa Rios | Licensing Program Manager | Oversaw licensing program related to the complaint investigation |
Inspection Report
Annual Inspection
Census: 76
Capacity: 100
Deficiencies: 1
May 7, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analyst Renee Campbell to evaluate compliance with licensing requirements.
Findings
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Four of seven resident files reviewed did not have record of Tuberculosis tests or chest x-rays with their results. | Type B |
Report Facts
Residents files reviewed: 7
Resident files missing TB tests or chest x-rays: 4
Facility capacity: 100
Census: 76
Facility temperature: 74
Hot water temperature room 201: 115
Hot water temperature room 206: 116
Plan of Correction due date: May 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the annual inspection and cited deficiencies |
| Tony Montellano | Executive Director | Met with Licensing Program Analyst during inspection |
| Janet Johns | Administrator/Director | Named as facility administrator/director |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 100
Deficiencies: 0
Mar 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were inappropriately charging residents for food delivery.
Findings
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.
Complaint Details
The complaint alleged inappropriate charging of residents for food delivery. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 100
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Montellano | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Renee Campbell | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 74
Capacity: 100
Deficiencies: 0
Apr 4, 2024
Visit Reason
An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations at the facility.
Findings
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.
Report Facts
Hot water temperature: 110.7
Hot water temperature: 114.4
Facility thermostat temperature: 75
Resident census: 74
Licensed capacity: 100
Resident bedridden capacity: 8
Hospice waiver capacity: 10
Staff files reviewed: 6
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the inspection and toured the facility |
| Tony Montellano | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 1
Mar 20, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure the resident received assistance and care with taking prescribed medications, posing a potential Health, Safety and Personal Rights risk. | Type B |
Report Facts
Capacity: 100
Census: 68
Deficiency count: 1
Plan of Correction Due Date: Apr 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the complaint investigation and presented findings |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
| Tony Monellano | Executive Director | Met with Licensing Program Analyst during inspection |
| Janet Johns | Administrator / Assistant Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 100
Deficiencies: 1
Feb 22, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on interviews and record reviews, 1 of 2 staff reported that they did not assist persons with self-administration as authorized by a person's physician, posing an immediate Health, Safety or Personal Rights risk to persons in care. | Type A |
Report Facts
Deficiencies cited: 1
Census: 89
Total Capacity: 100
Plan of Correction Due Date: Mar 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anneka Ogundipe | Health and Wellness Director | Met with Licensing Program Analyst during inspection and involved in medication error discussion |
| Renee Campbell | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the inspection |
| Tony Montellano | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 100
Deficiencies: 1
Feb 16, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide prompt access to review all resident records and to provide photocopies within two business days as required by CCR 87468.2(a)(19). | Type B |
Report Facts
Capacity: 100
Census: 78
Deficiencies cited: 1
Plan of Correction Due Date: 03/25/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Johns | Administrator | Named as facility administrator during investigation |
| Tony Montellano | Administrator | Met with during inspection |
| Renee Campbell | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 100
Deficiencies: 0
Sep 27, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff handled a resident in a rough manner.
Findings
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.
Complaint Details
The allegation that staff handled a resident in a rough manner was investigated and found unsubstantiated based on interviews and lack of evidence.
Report Facts
Estimated Days of Completion: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the complaint investigation |
| Janet Johns | Assistant Executive Director | Met with investigators during the complaint investigation |
Inspection Report
Annual Inspection
Census: 83
Capacity: 100
Deficiencies: 0
May 16, 2023
Visit Reason
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.
Findings
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.
Report Facts
Residents files reviewed: 10
Staff files reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the annual inspection and met with Executive Director |
| Anthonty Montellano | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Original Licensing
Census: 70
Capacity: 100
Deficiencies: 0
May 27, 2022
Visit Reason
Unannounced prelicensing visit conducted to evaluate the facility's readiness for licensing and compliance with regulations.
Findings
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.
Report Facts
Hot water temperature range: 105
Hot water temperature range: 120
Food supply duration: 2
Food supply duration: 7
Fire extinguisher inspection date: May 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Johns | Executive Director | Met during the inspection and interviewed |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection |
| Stephenie Doub | Licensing Program Manager | Oversaw the inspection |
Inspection Report
Original Licensing
Census: 75
Capacity: 100
Deficiencies: 0
Apr 22, 2022
Visit Reason
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.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Montellano | Administrator | Named as facility administrator participating in the evaluation. |
| Janet Johns | Participant in COMP II telephone interview. | |
| Jude De La Concepcion | Licensing Program Manager | Named as licensing program manager. |
| Bethany Hunter | Licensing Program Analyst | Named as licensing program analyst. |
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