306006344-7-31-2025-22-AS-AORZ-DKRQTZ-20250821122758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006344
Report Date: 07/31/2025
Date Signed: 07/31/2025 02:43:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2024 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20241011144206

FACILITY NAME:	COGIR OF BREA		FACILITY NUMBER:	306006344
ADMINISTRATOR:	FAYE, SAMUEL		FACILITY TYPE:	740
ADDRESS:	700 MADISON WAY		TELEPHONE:	(714) 681-0105
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	110	CENSUS: 70	DATE:	07/31/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cynthia Figueroa, Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff is insufficient to provide care and supervision to memory care residents
Kitchen staff is insufficient to provide meal services
Food service is insufficient in both quantity and quality

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility regarding a complaint received in the Regional Office. LPA was greeted and granted entry by the concierge and met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit.

LPA reviewed the following documents: Resident roster from October 2024, Personnel Report (LIC 500) dated October 15, 2024, and Kitchen Staff Schedule from 10/7-10/27/2024. LPA reviewed seven of seven resident files which include: Resident Dietary Orders/Food Preferences Form, Identification and Emergency Information, Physician's Report, and Admissions Agreement. Additional documents obtained and reviewed were: October 2024 Activities Calendar, October 2024 Transportation Calendar, and Bus Repair invoice.

The allegation that: Facility staff is insufficient to provide care and supervision to memory care residents was Substantiated on May 13, 2025 with Complaint Control Number:22-AS-20250509094345.
(Continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20241011144206

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COGIR OF BREA	FACILITY NUMBER: 306006344
	VISIT DATE: 07/31/2025

NARRATIVE

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(Continued from LIC 9099)

The Department interviewed thirteen of thirteen staff members, which include the former Chef and the current Chef at the facility. LPA also interviewed four of four alert residents.

Seven of thirteen staff confirmed that on October 9, 2024 the dining room staff walked off the premises during dinner service. Six of the thirteen staff members interviewed were not employees of the community during October 2024. None of the staff members denied that the incident occurred. Three of the four residents interviewed recalled the incident when dining room staff walked out and that management voluntarily returned to the community to serve dinner and a family member also brought meals to the community. One of four residents did not reside in the community during this time. The allegation that: Kitchen staff is insufficient to provide meal services is Substantiated. This allegation was addressed on May 13, 2025 with the allegation that: Facility is understaffed to provide services necessary to meet resident needs with Complaint Control Number:22-AS-20250509094345.

The Department conducted a ten day visit on October 15, 2024. LPAs interviewed the former Chef and spoke with three of three staff members. The Chef's interview stated the residents have access to food and that desserts, fruits and snacks are found in the bistro. LPAs took a photo of the bistro case and there observed three apples and six mini cakes in the glass casing. Three of the four residents LPA interviewed had various food issues and felt the food was not always accessible. In October 2024 there was a week between the former Chef leaving the community and the current Chef being cleared to work where food was not of adequate quantity or quality. This was primarily due to staffing shortages. Thus, the allegation that: Food service is insufficient in both quantity and quality is Substantiated.

Based on LPAs observations, document review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations: Facility staff is insufficient to provide care and supervision to memory care residents, Kitchen staff is insufficient to provide meal services and Food service is insufficient in both quantity and quality are Substantiated.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Cynthia Figueroa, Executive Director and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 9099-D and Appeal Rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20241011144206

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COGIR OF BREA	FACILITY NUMBER: 306006344
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/21/2025 Section Cited CCR 87555(b)(5)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. Based on LPA observations,	1 2 3 4 5 6 7	Facility will ensure there is adequate culinary line and server staff. Chef will submit menus to LPA by August 14, 2025 to provide documentation of food quality and minutes from the August Food Forum.
	8 9 10 11 12 13 14	and interviews, this requirement is not met as evidence by: Three of four residents stated food was not always accessible, low quantity, per photos taken 10/15/24, and quality. This poses a potential health and safety risk for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

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