306006344-6-10-2025-22-AS-APAO-DHKQ78-20250612115444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006344
Report Date: 06/10/2025
Date Signed: 06/10/2025 04:50:50 PM

Unsubstantiated

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 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: 51	DATE:	06/10/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Erin Hernandez, Community Relations Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not conduct proper appraisal to place residents in memory care
Staff does not have job training or experience in the job assigned to them

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint filed in our Regional Office on May 9, 2025.

It was alleged staff did not conduct proper appraisals to place residents in memory care due to facility moving Resident #1 (R1) and Resident #2 (R2) to facility memory care. Per R1’s physician report dated April 04, 2025, R1 has a diagnosis of dementia. Per interviews conducted with facility staff, five of five staff reported R1 was refusing showers causing concerns for R1’s hygiene. In addition, staff reported concerns that R1 would leave the facility without informing anyone and on one occasion accidently ran over their dog using their motorized scooter. Based on R1’s changing behaviors, the facility conducted a re-assessment on May 15, 2025.

Based on needs and service plan reviewed, R1 was assessed to have occasional disorientation to person place time or situation. In addition, it was determined R1 requires redirection and reminding from others.
(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025

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-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: 06/10/2025

NARRATIVE

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(Continued from LIC 9099)
A care plan meeting was held with facility representatives and R1’s family on May 20, 2025 and the decision was made not to move R1 to the facility memory care unit at this time and to remove R1’s motorized vehicle.

R2’s physician report dated December 08, 2024, lists R2’s diagnosis as Mild Cognitive Impairment and intermittent bladder incontinence. Furthermore, the physician report states R2 is not able to care for their own toileting needs. Interviews conducted with five of five facility staff and six of six residents reported concerns that R2 was exhibiting incontinence issues in the facility creating sanitary issues in facility common areas. On April 15, 2025, the facility conducted a re-assessment of R2 and determined R2 required extensive 1:1 hands on assistance with incontinence care. Per interview with Executive Director, the facility had a care plan meeting on April 15, 2025 with R2’s family and assessed not to move R2 to the facility memory care unit at this time. Following the re-assessment of R2 interviews with residents reported the sanitary concerns had improved.

It was alleged staff does not have job training or experience in the job assigned to them due to facility Chef overseeing the facility care floor. During LPA’s interview with Executive Director it was reported the facility Health and Wellness Director and Memory Care Director were not actively working at the facility beginning approximately May 8, 2025. Due to staffing shortages, the facility requested the facility Chef to assist with manager oversight over facility care floor staff. LPA conducted interview with Executive Director and facility Chef who both reported Chef’s role in overseeing the facility care floor was to provide managerial support to facility care staff. Both denied Chef was providing any direct care to facility residents and/or giving directions to facility care staff regarding care to residents.

LPA reviewed facility training records for Chef. Per records reviewed facility Chef has current updated training in all mandatory training topics including but not limited to Dementia, Ladder Safety, Fire Safety, Customer Service, Home Health, Sexual Harassment, Diversity, Spiritual Aging, Hiring, Active Shooter, and Hospitality. Interviews with eight of ten staff reported no concerns with Chef’s oversights. Two of ten staff reported concerns with the Chef’s oversight of facility care floor as he needed to remain in his area of expertise. Interviews with nine of nine residents reported no concerns. Per interviews with facility Executive Director the facility is actively hiring for the facility Health and Wellness Director position as well as Memory Care Coordinator. Effective May 13, 2025, the Facility Regional Nurse is on site providing oversight to facility care

(Continued on LIC 9099-C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025

LIC9099 (FAS) - (06/04)

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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: 06/10/2025

NARRATIVE

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(Continued from LIC 9099C)
floor. The facility has created a managerial schedule to ensure a manager is on site every day including weekends.

Based on LPA's observation, interviews and record review, the Department has determined that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegations that the: Staff did not conduct proper appraisals to place residents in memory care and Staff does not have job training or experience in the job assigned to them are Unsubstantiated.

An exit interview was conducted with Erin Hernandez, Community Relations Director and verbally read to Executive Director Cynthia Figueroa, and a copy of the report andthe List of Confidential Names (LIC 811) was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025

LIC9099 (FAS) - (06/04)

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