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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006344
Report Date: 08/21/2025
Date Signed: 08/21/2025 10:33:54 AM

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
03/10/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250310123459
FACILITY NAME:COGIR OF BREAFACILITY NUMBER:
306006344
ADMINISTRATOR:FAYE, SAMUELFACILITY TYPE:
740
ADDRESS:700 MADISON WAYTELEPHONE:
(714) 681-0105
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:110CENSUS: 69DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Cynthia Figueroa, Executive DirectorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff did not ensure the residents emergency pull and button was properly operating
Staff did not ensure the resident's outlets were properly operating
Staff mishandled a resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint investigation conducted by the Department. LPA was greeted and granted entry and met with Cynthia Figueroa, Executive Director (ED).

It was alleged Staff did not ensure the resident's emergency pull button was properly operating and Staff did not ensure the resident’s outlets were properly operating due to Resident #1 (R1)’s pull cord and outlets not working.

R1 moved into the facility on December 15, 2024. Upon moving into the facility, interviews conducted with R1’s family reported outlets were observed to be in working order but the call button and emergency pull cord was not working. The issue was brought to the facility maintenance director’s attention and R1 was offered to move rooms due to the emergency pull cord and call button not working. R1 was not moved into another room until January 4, 2025 which was eleven days later.
(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20250310123459
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: 08/21/2025
NARRATIVE
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(Continued from LIC 9099)

Based on LPA observations, record review and interviews the allegations that alleged Staff did not ensure the residents emergency pull button was properly operating and staff did not ensure the resident’s outlets were properly operating are Substantiated.

It was alleged that Staff mishandled a resident's medication. Facility progress notes from January 5, 2025 at 8:54pm document that a personal caregiver showered R1 and found three medication patches on R1’s right side; one on the shoulder and two on the bottom. This was reported to the Health and Wellness Director (HWD). Personal caregiver notified family of the three patches found on R1. HWD notified hospice and on January 10, 2025 a new patch was applied and former patches removed. A photo was submitted to the Department of multiple patches on R1. Per physician’s report dated December 12, 2024 one medication patch was to be applied daily.

Therefore, the allegation that Staff mishandled a resident's medication is Substantiated. This was cited on June 18, 2025 for Control # 22-AS-20250416144122 with the allegation that: Staff are mismanaging residents medications. The Plan of Correction documentation was submitted to the Department that the staff received medication storage and destruction trainings on June 24th and June 30, 2025.

Based on LPA's observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations: Staff did not ensure the residents emergency pull and button was properly operating, Staff did not ensure the resident's outlets were properly operating and Staff mishandled a resident's medication are found to be 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 (ED) and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 859; LIC 9099-D and Appeal Rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250310123459
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: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
87303(i)
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87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...shall have a signal system which shall: (A) Operate from each resident's unit. (B) Transmit a visual and/or auditory (cont.)

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Executive Director and LPA toured Memory Care and tested the signal system. The signal system was in working order. The Plan of Correction wil be cleared by the visit today on August 21, 2025.
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signal to a central staffed location or produce an auditory signal... loud enough to summon staff. (C) Identify the specific resident living unit. This requirement was not met as evidenced by: Resident call button was not in working order which poses an immediate health and safety risk to persons in care.
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Type A
08/22/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (cont.)
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Executive Director and LPA toured Memory Care and tested outlets in resident room. Outlets were tested and in working order. The Plan of Correction will be cleared by the visit today on August 21, 2025.
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This requirement was not met as evidenced by: Resident outlets were not in working order. This poses an immediate health and safety risk to persons in care.
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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: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
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