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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006344
Report Date: 05/13/2025
Date Signed: 05/13/2025 04:55:05 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
05/09/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250509094345
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: 52DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Whitney Blake, Regional Vice President of OperationsTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is understaffed to provide services necessary to meet resident needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to continue an investigation of a complaint received in our Regional Office. LPA was greeted and granted entry and met with Regional Vice President of Operations (RVPO) Whitney Blake.

At 8:15am on May 12, 2025, LPA toured the facility and visited Memory Care. LPA observed one caregiver for Memory Care (MC) with nine residents, one Med Tech covering both Assisted Living (AL) and MC and one caregiver designated for AL with forty-three residents for the morning shift. One caregiver was assisting the culinary department. LPA interviewed seven residents and nineteen staff members. All nineteen of nineteen staff members, from various departments, confirmed the care department was short-staffed.

LPA obtained a copy of the resident and staff rosters, the April and May care staff schedules, and payroll documentation from March 21 through May 12, 2025.
(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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-20250509094345
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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2025
Section Cited
CCR
87411(a)
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Personnel Requirements - General
87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of
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This requirement is not met as evidenced by: Based on LPA observation and interviews of residents and staff on May 12-13, 2025, facility is understaffed to provide services necessary to meet resident needs. This poses an immediate health and safety risk to residents in care.
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personal assistance and care...The licensing agency may require any facility to provide additional staff whenever it determines...that the needs of the particular residents, the extent of services provided... require such additional staff for the provision of adequate services.
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Regional Vice President of Operations pulled care staff from another department to have adequate staffing on May 12, 2025. National Clinical Nurse, Regional Nurse and Health and Wellness Nurse from the sister community provided additional staff support on May 13, 2025.
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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: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250509094345
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: 05/13/2025
NARRATIVE
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(Continued from LIC 9099)

Based on LPA's observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation that the: Facility is understaffed to provide services necessary to meet resident needs is Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with Whitney Blake, Regional Vice President of Operations, and a copy of this report, 9099-D, and Appeal Rights were provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3