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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701180
Report Date: 07/02/2026
Date Signed: 07/02/2026 03:20:42 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/02/2026 03:20 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COGIR OF TURLOCKFACILITY NUMBER:
502701180
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, JACKIEFACILITY TYPE:
740
ADDRESS:3791 CROWELL ROADTELEPHONE:
(209) 664-9500
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY: 100CENSUS: DATE:
07/02/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jackie HernandezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to continue an annual inspection. LPA Met with Executive Director Jackie hernandez to explain the purpose of the visit.

On the previous visit, LPM reviewed 11 resident files of which 4/11 were hospice residents and 4/11 resided in the MC section of the community. During the file review the LPM reviewed associated incident reports ensuring the RP and MD were notified, medication orders were addressed and if a change of condition occurred an updated care plan was developed. 2 residents had a change of condition which would have triggered an updated reappraisal. tDuring the inspection, the weight logs, service notes and ADL charting were not reviewed. LPA has returned today to address any concerns related to these.

Pullcord log from the last three weeks were reviwed, common reason is toilet/bathing, common response time is 20 seconds to 4 minutes, a few outlier times are 9-13 minutes.

Weight logs are completed for residents with relevant issues to sudden changes in weight. no concerns.

Service notes/ADL charting describes in detail the Bowel Movement, bathing, incontinence care, grooming, and shower habits appropriately to the concern of the residents. Logs have created by dates and authors consistant with daily use of the log. no concerns excepting R4 med error morphine double dose 02162026.

Citations were issued. a copy of the report was read and given to the executive director. appeal rights were provided, exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2026
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 07/02/2026 03:20 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 07/02/2026 at 01:37 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COGIR OF TURLOCK
FACILITY NUMBER: 502701180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2026
Section Cited
CCR
87465(a)(2)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(2) The licensee shall provide assistance in meeting necessary medical and dental needs...
This requirement was not followed as evidnced by:
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No POC, the employee was given the rights of medication training again, and the incident was self reported by the next shit medtech when count was discovered to be off the following day. resident/hospice were informed.
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Record review of log notes(2/16/2026) for a resident(r4) where medication(morphine) should have been given as a half dose and was instead given as a full dose.

Not following this requirement poses a risk to the health and safety and personal rights of a resident in care.
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Type B
07/30/2026
Section Cited
CCR87463(b)

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87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.

This requirement was not followed as evidenced by:
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LPA suggested an signed understanding of the administrator of 87463 and 87466, and then updated these two residents needs and services plans
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Of the 11 files reviewed, R5(fall 0512026), and R12 ( 02032026 addtion of home healthwoundcare) did not have an updated CP when there was a change in condition.

Not following this requirement posed a risk to the health, saftey, or personal rights of clients 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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


LIC809 (FAS) - (06/04)
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