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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006344
Report Date: 06/18/2025
Date Signed: 06/18/2025 06:11:59 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
04/16/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250416144122
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: 54DATE:
06/18/2025
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Cynthia Figueroa, Executive DirectorTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff are mismanaging residents medications
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Hanna Gough and Rose Ruppert conducted an unannounced visit to deliver findings. LPAs met with Executive Director (ED), Cynthia Figueroa.

It was alleged staff are mismanaging residents medications due to Resident #6’ (R6)s narcotics not being destroyed in a timely manner and that destruction protocols were not being followed. Furthermore, it was reported residents bubble packed medications were stored and mixed together. During LPA’s visit on April 24, 2025, LPA Ruppert reviewed facility medications which appeared to be in order meaning bubble packed medications were not being stored and mixed together and Narcotics were logged and initialed on facility narcotics logs.

Narcotic logs were obtained for all facility narcotics dated March 27, 2025, through April 24, 2025. Interviews conducted with four of four facility med techs confirmed that bubble packed medications may
(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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 4
Control Number 22-AS-20250416144122
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: 06/18/2025
NARRATIVE
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(Continued from LIC 9099)

get mixed on occasion and are audited by the facility Memory Care Director (MCD) for accuracy.

Per facility surveillance camera footage obtained, facility Executive Director Dyan Summerell found narcotics from a deceased resident (R6) in facility Memory Care Director's desk. Per facility records, R6 passed away on March 24, 2025. Narcotics were discovered by ED Summerell on May 07, 2025. Per facility medication destruction protocol, medications are to be destroyed or returned to dispensing pharmacy upon a resident passing.

An interview with interim Health and Wellness Director (HWD) stated the medications are destroyed immediately, upon a resident's passing, with a designated staff member and another adult witness who is not a resident. HWD and ED Summerell destroyed medications upon discovery in MCD's office on May 12, 2025. Facility Memory Care Director was placed on leave effective May 05, 2025, unrelated to the undestroyed medications incident. Following discovery of the undestroyed medications, facility Memory Care Director was terminated from the facility.

Based on LPAs' observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation that Staff are mismanaging resident medications is found to be Substantiated California Code of Regulations (Title 22, Division 6 Chapter 8) are being cited on the attached LIC 9099-D.

An exit interview was conducted with ED Figueroa and a copy of this report, the LIC 9099-D, LIC 811 Confidential Names and Appeal Rights were given at time of visit.

****This is an amended report.****
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250416144122
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: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2025
Section Cited
CCR
87465(i)
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87465(i) Incidental Medical and Dental Care: Prescription medications which are not taken with the resident upon termination of services... disposed of... .shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least
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ED stated they will provide an in-service to all staff on medication storage and destruction and will send documentation of in-service to LPA by POC due date. Medications were disposed of on May 12, 2025.
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three years. This requirement has not been met as evidenced by: LPAs observations show resident passed on 3/24/2025 and meds were not destroyed until 5/12/2025. A signed record was not found. This poses a potential health and safety risk to residents 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: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250416144122
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: 06/18/2025
NARRATIVE
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(Continued from LIC 90990-C)

****THIS IS AN AMENDED REPORT****

This page was incorrectly placed under the Substantiated LIC 9099)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4