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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 12/11/2025
Date Signed: 12/11/2025 11:00:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251013105535
FACILITY NAME:COGIR OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:JIM SIDOTIFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 58DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Jim SidotiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not safeguard Resident's Personal Belongings
Illegal Rate Increase
INVESTIGATION FINDINGS:
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On 12/11/2025, Licensing Program Analyst (LPA) Murial Han and Licensing Program Analyst (LPA) John Calandra conducted an unannounced visit to deliver the complaint investigation findings. LPA met with administrator and explained the purpose of today's visit.

Regarding the allegation of- facility did not safeguard Resident's Personal Belongings, the reporting party stated that resident-in- question (R1) and all the residents were evacuated to another facility due to an electrical emergency. When R1 returned, R1's personal items were missing from R1's room.

As part of the investigation, LPA interviewed the Regional Vice President of Operations, R1, R1's family member, and reviewed documents.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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 10
Control Number 14-AS-20251013105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COGIR OF BELMONT
FACILITY NUMBER: 415601080
VISIT DATE: 12/11/2025
NARRATIVE
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The Regional Vice President of Operations stated she has seen photos of the missing furniture in R1's room before and after the relocation but she stated that she did not have any specific details because it was handled by the previous management company, Integral Senior Living (ISL) and they did a major clean up before the residents returned.

According to R1, many furniture and other personal belongings were missing from the apartment after returning to the facility. R1 also stated that a laptop was missing, many garbage bags that were packed with personal items were thrown away without his/her permission.

According to R1's family member, they made a police report after discovering the furniture and other items were missing from R1's apartment and they have photos to proof. R1's family member stated that they have shared these photos with Cogir management, and they were told that they would be reimbursed when the police report was finalized.

Based on the before and after photos of R1's apartment, it revealed that many furniture was missing such as a bookshelf, table, chairs, entry furniture, etc.

Based on the written communication dated February 4, 2025, the Regional Vice President of Operations stated that the facility will reimburse R1's family member for the missing items when the police report was finalized. However, a copy of the police report dated 2/18/2025 was provided but the reimbursement was not issued.

After the investigation, this allegation is deemed to be substantiated because there was photos to proof that furniture and other items were missing from R1's apartment after R1's returned to the facility, and there was a written communication in February 2025 from the Regional Vice President stating that R1 will be reimbursed but as of today, R1 and R1's family member has yet been reimbursed.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 14-AS-20251013105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COGIR OF BELMONT
FACILITY NUMBER: 415601080
VISIT DATE: 12/11/2025
NARRATIVE
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Regarding the allegation of - illegal rate increase, the reporting party stated that the facility increased R1's rent and charged for the administrative work.

As part of the investigation, LPA interviewed R1, R1's family member, the State Official, the Director Of Health Services, the Administrator, the Business Office Director, and the Regional Vice President Of Operations.

According to R1, the facility increased the rate for level of care and it was based on an assessment but R1 did not remember having any type of assessments. In addition, R1 stated that R1's family member was forced to pay for the increase as R1's family member did not want the facility to evict R1 due to non-payment.

According to R1's family member, initially the facility stated that the level of care increased was a mistake as the billing was done by an outside company and it would be corrected. However, in February 2025, the facility informed them that there would be a level of care increase starting March 2025 due to extra care. R1's family member stated that R1 did not require any extra care, and they have never gotten a written notice of the level of care increase and an explanation of the increase.

LPA interviewed the Administrator and the Director Of Health Services, and neither could provide any details as they were both new to the facility.

LPA interviewed the Business Office Director who did not have any details pertaining to the level of care increase but stated that R1's family member has been paying the additional level of care increase since April 2025.

LPA interviewed the Regional Vice President of Operations who stated that the monthly rent was increase due to R1's behaviors.

LPA interviewed the State Official who stated that he/she was invited to a meeting in February 2025 with the Regional Vice President of Operations and R1's family member to discuss the level of care increase but during the meeting, there was no conversation about the care, it was about R1's behaviors that triggered the level of care.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 14-AS-20251013105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COGIR OF BELMONT
FACILITY NUMBER: 415601080
VISIT DATE: 12/11/2025
NARRATIVE
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Based on R1's care plan detail dated 12/30/2024, R1 was independent and did not require care. In addition, the care plan detail was not signed by the resident, the party responsible and facility representative to proof that it was reviewed and discussed accordingly.

After the investigation, this allegation is deemed to be substantiated as the facility increased R1's level of care but based on R1's care plan detail dated 12/30/2024, R1 did not have any care needs. In addition, R1 and R1's family member did not receive a written notice with details explaining the level of care increase.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrator, and Appeal Rights provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 14-AS-20251013105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: COGIR OF BELMONT
FACILITY NUMBER: 415601080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2025
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.
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The administrator will discuss with the Regional VP on an action to address this finding and the administrator will provide a plan of correction to prevent this from happening again.
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This requirement is not met as evidenced by based on interview, records review and observation, R1 was evacuated to another facility due to an electrical issue at the facility and upon returned, R1 and R1's responsible party discovered many items were missing that were there before which posed a potential health and safety risk to residents in care.
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The administrator will provide a copy of the plan of correction to CCL by 12/18/2025.
Type B
12/18/2025
Section Cited
CCR
1569.657(a)
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§1569.657Rate increase due to change in level of resident care; notice(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative,.. written notice of the rate increase.. The notice shall include a detailed
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The administrator will discuss with the Regional VP on an action to address this finding and the administrator will provide a plan of correction to prevent this from happening again.
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explanation.. This requirement is not met as evidenced by based on record review, and interview R1 and R1's responsible party was not provided a written notice of the level of care increase which poses a potential health and safety risk to resident in care.
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The administrator will provide a copy of the plan of correction to by 12/18/2025.
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: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251013105535

FACILITY NAME:COGIR OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:JIM SIDOTIFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 58DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Jim SidotiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff Violated Personal Rights
Facility provided false assessmentl to CCL to support the eviction
INVESTIGATION FINDINGS:
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On 12/11/2025, Licensing Program Analyst (LPA) Murial Han and Licensing Program Analyst (LPA) John Calandra conducted an unannounced visit to deliver the complaint investigation findings. LPA met with administrator and explained the purpose of today's visit.

Regarding the allegation of- staff violated personal rights, the reporting party stated that the facility does not have a phone that resident-in-question (R1) can use, staff #1 (S1) stayed in the lobby to talk to the receptionist (S2) which made R1 felt that there was no privacy in the lobby when R1 wanted to talk to the receptionist and the facility paid for a mover for the other residents to return to the facility after the emergency evacuation except for R1.

As part of the investigation, LPA interviewed S1, S2, staff #3 (S3), the Administrator, the Business Office Director, Regional Vice President of Operations, the Stated Official, and other residents.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 14-AS-20251013105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COGIR OF BELMONT
FACILITY NUMBER: 415601080
VISIT DATE: 12/11/2025
NARRATIVE
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Regarding the phone services, the Administrator and the Business Office Manager stated that the phone on the 3rd floor is always available for residents to use. They also stated that R1 utilized that phone as well as the phone in S3's office to make confidential calls.

According to R1, there is a phone of the 3rd floor, and he/she has been using that phone, but it is not always available. R1 also stated that he/she has been using the phone in S3's office to make confidential calls and R1 stated that he/she has a cell phone.

According to S3, R1 has been going to S3's office very often to use the phone and S3 would leave the office to private privacy. S3 reported that there were times when R1 spent a long time on the phone where S3 needed to tell R1 that she needed to do something in the office.

According to the State Official, the facility has been accommodating R1 with providing a phone services.

Regarding S1 staying in the lobby and talking to the receptionist and/or other staff after S1 clocked out for work, LPA interviewed S1, the Administrator, S2, and other residents.

According to S1, he/she stayed after work to decompress after a long day of work by talking to different people. S1 stated that he/she did not bother anyone by doing that.

According to the Administrator, the lobby area is not a private space to have any private conversation. The administrator stated lobby is a common space for everyone to use including S1, other staff members, visitors, residents, etc. The Administrator stated that when a resident wants to have a private conversation with a staff, it will be conducted at a private space.

LPA interviewed other residents and all of them reported that their privacy was honored by the facility.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 14-AS-20251013105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COGIR OF BELMONT
FACILITY NUMBER: 415601080
VISIT DATE: 12/11/2025
NARRATIVE
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Regarding hiring professional movers to assist with moving residents back to the facility due to the emergency evacuation except for R1, R1 stated that the other residents were provided with a company credit card to pay for the movers except for R1.

According to the State Official, R1 was very particular of the transportation arrangement and R1 arranged for a friend who has a van to drive R1 back to the facility. The State Official stated that some other residents moved their furniture to their temporary location but R1 did not, so the van was big enough to fit all of R1's belongings.

According to the Regional Vice President of Operations, the relocation arrangements were made by the previous management, ISL and she did not have the details.

After the investigation, this allegation is deemed to be unsubstantial.

Regarding the allegation of - facility provided false assessment to CCL to support the eviction, the reporting party stated that the facility provided false unusual incident reports concerning to R1 to CCL of the events that never happened.

As part of the investigation, LPA interviewed R1, the Administrator, and reviewed unusual incident reports.

According to R1, the facility reported false incidents to CCL, for example, he/ she was yelling and screaming, wearing inappropriate attire in the public area, and the facility provided accurate information to the mobile crisis team that resulted in R1 being hospitalized.

According to the Administrator, the facility was following the reporting requirement by reporting the incidents that were observed. The Administrator stated that there were a couple of events that triggered a call to a local community outreach support agency and R1 was taken to the hospital for further evaluation based on their assessment of the situation.

Based on the incident reports submitted by the facility, each of them indicated an unusual incident that happened at the facility which triggered the facility to report it to the Department as part of the Reporting Requirement under Title 22.

After the investigation, this allegation is deemed to be unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251013105535

FACILITY NAME:COGIR OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:JIM SIDOTIFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 58DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Jim SidotiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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On 12/11/2025, Licensing Program Analyst (LPA) Murial Han and Licensing Program Analyst (LPA) John Calandra conducted an unannounced visit to deliver the complaint investigation findings. LPA met with administrator and explained the purpose of today's visit.

Regarding allegation of illegal eviction- the reporting party stated that the facility provided a 30-day eviction notice to resident #1 (R1) as form of retaliation from filing a lawsuit.

As part of the investigation, LPA interviewed the Administrator, and reviewed documents.

The Administrator denied the allegation and stated that on August 29, 2025, R1 was provided with a copy of the 30-day notice to terminate and the letter indicated the events supporting the termination. The Administrator also stated that the letter included resources for R1 to file a complaint if R1 disagreed with the termination.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 14-AS-20251013105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COGIR OF BELMONT
FACILITY NUMBER: 415601080
VISIT DATE: 12/11/2025
NARRATIVE
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Based on the eviction letter, it indicated the reasons supporting the eviction, and other required resources. In addition, a copy of the letter was provided to CCL.

After the investigation, this allegation is deemed to be unfounded as the facility provided proper notification to R1 and to the Department according to Title 22 Regulation- Eviction Procedures.

Based on interviews, record review, and observations, the department has determined that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED.

Report is reviewed and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 10 of 10