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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006344
Report Date: 07/22/2025
Date Signed: 07/22/2025 11:43:03 AM

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
07/21/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250721114004
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: 62DATE:
07/22/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Cynthia Figueroa, Executive Director (ED)TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility left resident unattended for an extended period of time
Facility did not provide care and supervision resulting in multiple falls
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in our Regional Office. LPA met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit.

LPA came to investigate the allegations that: Facility left resident unattended for an extended period of time and Facility did not provide care and supervision resulting in multiple falls.

LPA obtained and reviewed the following: Resident Roster, Care Staff schedule from 6/29-7/31/2025, Copy of Unusual Incident Report faxed to Regional Office on July 19, 2025 and facility policy for Alert Charting. LPA obtained the following from Resident #1's file: Identification and Emergency Information Form, Preappraisal Information, Physician's Report dated 2/06/2025 and Appraisal and Service Plans from 5/13/2025 and Admissions Agreement.
(Continued on LIC 9099-C)


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
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 2
Control Number 22-AS-20250721114004
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: 07/22/2025
NARRATIVE
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(Continued from LIC 9099)
LPA toured the facility and was permitted entry in Resident #1 (R1's) apartment by Care Staff. LPA conducted six of six staff interviews, three of three witness interviews and interviewed the Executive Director (ED regarding the incident that occurred on Saturday, July 19, 2025.

LPA reviewed documents and noted on the Appraisal, Services Plan and Physician's Report that Resident #1 (R1) is independent and only requires assistance with medication. Although R1 does not receive alert charting care for two hour checks, staff continually check on R1; especially if R1 strays from the normal routine. R1 keeps to self and felt the frequent checks were not necessary and wears a bracelet call button. R1 is able to toilet and bathe independently and when staff inquire if R1 needs assistance, R1 does not request assistance. R1 rarely presses the bracelet pendant and was not wearing it at time of fall.

On the date of the unwitnessed fall, R1 was found by AM Medical Technician (Med Tech) when entering the apartment to give medications at 8:30am. Responsible Party and Emergency Medical Services (EMS) were immediately called and R1 was transported to a local hospital for evaluation. R1 was admitted to the hospital for further observation.

It was reported by AM Med Tech to EMS that R1 received meds at 8pm. ED also observed R1 the day before and did not note anything unusual and observed R1 playing Bingo. PM Med Tech did not notate any changes in condition in charting. Photo documentation was obtained and staff members on-site, at the time of the incident, noted the urine and feces were fresh and that R1 had not been left for an extended period of time.

Record review did not show that Resident #1 (R1) has had any falls since admission on April 10, 2025. The incident on July 19, 2025 was the first fall for the resident in the community.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations that: Facility left resident unattended for an extended period of time and Facility did not provide care and supervision resulting in multiple falls are Unsubstantiated. An exit interview was conducted with Executive Director (ED) Cynthia Figueroa and a copy of the report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2