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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 08/12/2026
Date Signed: 08/12/2026 07:48:31 PM

Document Has Been Signed on 08/12/2026 07:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COTTAGES AT HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR/
DIRECTOR:		BARBARA BOGOJEFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 91DATE:
08/12/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:19 PM
MET WITH:Barbara Bogoje, Executive Director TIME VISIT/
INSPECTION COMPLETED:
07:55 PM
NARRATIVE
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On 08/12/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross, arrived at the facility to issue a Case Management deficiency for Complaint Control #18-AS-20250220134327. It was determined that R1’s Needs and Services Plan dated 06/08/2024 identifies R1 as a Fall Risk, with two prior falls documented on 11/06/2024 and 01/11/2025. Facility records, including the Unusual Incident/Injury Report and chart notes dated 02/18/2025, indicate R1 was found on the floor outside the bathroom door near the closet.
Review of the Personal Care Assistant (PCA) job description shows that staff are required to conduct rounds every two hours. Interviews with staff revealed, if a resident is a fall risk, then rounds should be conducted every hour.

R1 was last seen after being escorted by staff to their room following dinner. Staff interviews confirmed that at approximately 10:30pm a staff walked by R1’s room; however, staff did not open R1’s door to visually check on R1. R1 was discovered by staff, calling for help at approximately 4:00am.
Interviews with multiple relevant parties revealed R1 reported to the relevant parties, that the fall occurred between 10:00pm – 10:30pm after their walker became caught on something, causing them to fall backward and strike their head on the bedside.

Thus concluding, R1 remained on the floor for an estimated six hours before being found due to the neglect of staff to conduct rounds in accordance with the facility’s procedures.

A citation was issued and discussed with Barbara Bogoje, Executive Director and a copy of this report, and appeals rights was provided.
Rikesha Stamps
Jacqueline Shaw Ross
DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/12/2026 07:48 PM - It Cannot Be Edited


Created By: Jacqueline Shaw Ross On 08/12/2026 at 06:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COTTAGES AT HEMET
FACILITY NUMBER: 331800055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2026
Section Cited
CCR
87465(a)(1)

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The licensee shall ensure that residents receive care and supervision...requires the facility to have planned procedures and immediate capabilities to respond to medical needs....This requirement was not met as evidenced by:
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An in-service training will be conducted with medtechs and care staff on having knowledge of residents care plans and fall risks residents, and making rounds. Documentation of this training will be provided to the Department by POC 8/26/26.
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Based on interviews and record reviews,staff failed to conduct rounds every 1 to 2 hours for residents who are a falll risk, leaving resident unobserved and unattended for 6 hours after a fall. This posed an immediate health and safety risk for resident.
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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.
Rikesha Stamps
NAME OF LICENSING PROGRAM MANAGER:
Jacqueline Shaw Ross
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2026


LIC809 (FAS) - (06/04)
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