Inspection Reports for Cogir of Folsom Memory Care
1801 E Natoma St, Folsom, CA 95630, United States, CA, 95630
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, there were substantiated deficiencies primarily related to medication management, staff supervision, and resident rights, including serious incidents such as a resident’s death due to inadequate supervision and staff working without required criminal record exemptions. The facility received civil penalties totaling at least $15,500 for these issues, with the most recent deficiency-free report dated September 16, 2025, showing improvement. Earlier reports documented medication errors, failure to update medical records, and food safety violations, but recent inspections reflect corrective actions and better compliance. Overall, the facility’s record shows a mix of challenges that have been addressed over time, with recent visits indicating progress.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
64% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 42
Capacity: 66
Deficiencies: 0
Date: Sep 16, 2025
Visit Reason
The visit was an unannounced office meeting held to discuss recent non-compliance at the facility.
Findings
The meeting covered significant leadership changes, continuation of staff training, observation of residents' behavior expressions, and appropriate oversight at the facility. No deficiencies were issued in this report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly McMurray | Senior Vice President of Care and Compliance | Present in the meeting and recipient of the emailed report. |
| Kristina Munoz | Senior Vice President Operations Northern CA | Present in the meeting. |
| Justin Stein | Assistant Chief Operating Officer | Present in the meeting. |
| Kimberly Eldridge | National Director of Resident Care | Present in the meeting. |
| Karen Silva | Regional of Health and Wellness | Present in the meeting. |
| Joel Goldman | Legal representative | Present in the meeting. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 0
Date: Sep 10, 2025
Visit Reason
The inspection visit was an unannounced case management visit conducted regarding a SOC 341 report submitted by the facility concerning a sexual incident between two residents.
Complaint Details
The visit was triggered by a complaint report (SOC 341) regarding a sexual incident between residents R1 and R2. The complaint was investigated, and no deficiencies were found.
Findings
The facility notified law enforcement, the long term care ombudsman, and residents' responsible parties about the incident. The facility implemented one-on-one care and supervision for the involved resident pending further medical evaluation. No deficiencies were cited during the visit.
Report Facts
Capacity: 66
Census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit |
| Elizabeth Cruz | Administrator/Director | Met with Licensing Program Analyst during the visit |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 1
Date: Sep 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-02-25 regarding staff not updating resident medical records, inadequate supervision resulting in a resident fall, failure to seek medical attention, failure to notify the resident's responsible party, and facility maintenance issues.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not update the resident's medical records, leading to the resident being sent to the wrong medical facility. The allegation of inadequate supervision resulting in a resident fall was unsubstantiated. The allegations that staff did not seek medical attention and did not notify the resident's responsible party were unfounded.
Findings
The investigation substantiated the allegation that staff did not update a resident's medical records, resulting in the resident being sent to the wrong medical facility. The allegation of inadequate supervision resulting in a resident fall was unsubstantiated. The allegations that staff did not seek medical attention and did not notify the resident's responsible party were unfounded. The facility's AC/heater wall unit was found to be in good condition and not a danger to residents. A deficiency was cited for failure to update resident medical records with correct emergency physician information.
Deficiencies (1)
Licensee did not comply as resident record did not have updated medical physician information, resulting in resident being transported to wrong emergency medical facility, posing potential risk.
Report Facts
Capacity: 66
Census: 43
Deficiency count: 1
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Deborah Taylor | Administrator | Facility administrator during inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
The inspection was conducted as a follow-up on substantiated allegations resulting from a complaint investigation regarding lack of care and supervision that led to serious bodily injury and death of a resident.
Complaint Details
The complaint investigation substantiated allegations that due to facility staff's lack of care and supervision, a resident sustained serious bodily injury and another resident died. An immediate civil penalty of $500 was issued on December 23, 2024, and an additional civil penalty of $14,500 was issued on August 19, 2025.
Findings
The Department substantiated that facility staff's inadequate supervision resulted in a fatal altercation between residents, leading to a resident's death. A civil penalty was issued for violations of California Code of Regulations Title 22, § 87468.2(a)(4) concerning Personal Rights of Residents.
Deficiencies (1)
Violation of California Code of Regulations Title 22, § 87468.2(a)(4) Personal Rights of Residents in All Facilities due to lack of care and supervision resulting in serious bodily injury and death.
Report Facts
Civil penalty amount: 14500
Immediate civil penalty amount: 500
Facility capacity: 66
Resident census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the follow-up inspection and signed the report. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
| Liz Cruz | Facility Representative | Met with licensing staff during the inspection to discuss findings. |
| Deborah Taylor | Administrator/Director | Facility Administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
The visit was a case management inspection continuing a complaint investigation regarding deficiencies observed, including staff working without a criminal record exemption and medication errors affecting a resident.
Complaint Details
The visit was complaint-related, continuing an investigation into staff working without criminal record exemption and medication errors affecting a resident. The complaint was substantiated with deficiencies cited.
Findings
The investigation found that a staff member worked without a required criminal record exemption since September 2024 and was only removed from the schedule after discovery. Additionally, a resident missed approximately 30 days of routine medications due to unresolved issues with medication refills and lack of an active primary care physician on file.
Deficiencies (1)
Executive Director knowingly failed to comply with criminal record regulations and failed to assist resident to ensure medications are given as prescribed, posing a potential risk for residents in care.
Report Facts
Plan of Correction Due Date: Aug 26, 2025
Medication Missed Duration (days): 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Administrator/Executive Director | Named in findings for failure to comply with criminal record regulations and medication oversight |
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 2
Date: Aug 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that the licensee did not ensure staff were qualified for assigned duties and that staff mismanaged residents' medications.
Complaint Details
The complaint was substantiated based on evidence that staff did not have required criminal clearance and that medication was not administered as prescribed. The substantiation means the allegations were valid based on the preponderance of evidence.
Findings
The investigation substantiated that a staff member worked without the required criminal record exemption, violating personnel requirements, and that a resident was not administered a prescribed medication dose, confirming medication mismanagement.
Deficiencies (2)
Staff member (S1) worked at the facility without obtaining the required criminal record exemption.
Resident (R1) was not administered one dose of prescribed pentoxifylline medication as required.
Report Facts
Capacity: 66
Census: 44
Medication tablets missing: 1
Plan of Correction due date: Aug 20, 2025
Plan of Correction due date: Aug 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Deborah Taylor | Administrator | Facility administrator at time of investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff neglect resulted in resident dehydration and hospitalization.
Complaint Details
The complaint was substantiated. The allegation was that staff neglect resulted in resident dehydration and hospitalization. An immediate civil penalty of $500 was assessed for the injury due to staff neglect. The civil penalty assessment is under review and may be increased upon follow-up.
Findings
The investigation substantiated the allegation that staff neglect led to a resident (R1) being lost during a fire drill, resulting in heat exposure, dehydration, acute kidney injury, and hospitalization. Staff failed to conduct a required head count after the fire drill, allowing the resident to escape unnoticed for hours, posing an immediate health and safety risk.
Deficiencies (1)
Failure to be aware of the resident's general whereabouts during a fire drill, resulting in the resident escaping to a locked courtyard unnoticed for hours, causing injury and posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 500
Capacity: 66
Census: 44
Plan of Correction Due Date: Aug 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Deborah Taylor | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to multiple incident reports submitted earlier in the month concerning various resident incidents.
Complaint Details
The visit was complaint-related, triggered by multiple incident reports involving resident aggression, transport for evaluation, inappropriate resident behavior, and incidents causing physical altercations among residents. The reports were submitted late, violating reporting requirements.
Findings
The inspection found that the licensee failed to comply with reporting requirements, as approximately 17 incident reports were submitted late, exceeding the seven-day timeframe, posing a potential risk to residents in care.
Deficiencies (1)
Licensee did not comply as Licensing Program Analyst received approximately 17 incident reports that exceeded the seven days timeframe, which poses a potential risk for residents in care.
Report Facts
Incident reports received late: 17
Capacity: 66
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Deborah Taylor | Administrator/Director | Facility Administrator/Director mentioned in the report. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident report received regarding a medication error involving a resident who missed medications for over 30 days due to lack of an active primary care physician.
Complaint Details
The complaint was substantiated as the incident report revealed a medication error where resident R1 missed all medications for over 30 days due to no active primary care physician. The issue was addressed and resolved during the investigation.
Findings
The inspection found that the facility failed to ensure the resident received medications for more than 30 days, posing an immediate health and safety risk. The issue was resolved after the resident obtained a primary care physician who prescribed medication refills. Deficiencies were cited related to this medication error.
Deficiencies (1)
Failure to develop and implement a plan for incidental medical and dental care, resulting in a resident missing medications for more than 30 days.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Aug 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 47
Capacity: 66
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
The inspection was a required annual unannounced visit to evaluate the facility's compliance with licensing requirements, including discussion of a COVID-19 outbreak and staffing protocols.
Findings
The Licensing Program Analyst met with the Executive Director to discuss six active COVID-19 cases at the facility and staffing and COVID-19 protocols. The walk-through inspection was deferred to a later date.
Report Facts
Active COVID-19 cases: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Executive Director | Met with Licensing Program Analyst during inspection |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 45
Capacity: 66
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
The inspection was a case management annual continuation visit to ensure the health and safety of residents in care.
Findings
The facility was found to be clean, in good repair, and compliant with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.
Report Facts
Resident records reviewed: 5
Personnel records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Executive Director | Met with Licensing Program Analyst during inspection |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Census: 45
Capacity: 66
Deficiencies: 0
Date: May 29, 2025
Visit Reason
A Non-Compliance Conference was held to address previous compliance history and develop a non-compliance plan with the licensee.
Findings
The licensee was in agreement with the drafted non-compliance plan. Due to improvements and new procedure implementation, no citations were issued as a result of the meeting.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Executive Director | Facility representative present at the Non-Compliance Conference. |
| Phil Altman | Senior Vice President of Operations | Facility representative present at the Non-Compliance Conference. |
| Lyndee Whaley | Regional Vice President of Operations | Facility representative present at the Non-Compliance Conference. |
| Shayla Hill | Health and Wellness Director | Facility representative present at the Non-Compliance Conference. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 66
Deficiencies: 0
Date: May 2, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff left a resident unattended for an extended period resulting in hospitalization and that staff were not meeting residents' needs.
Complaint Details
The complaint included allegations that staff left a resident unattended leading to hospitalization and that staff were not meeting residents' needs. The investigation found these allegations to be unfounded based on medical records, staff interviews, and training documentation.
Findings
The investigation included file reviews and interviews, concluding that both allegations were unfounded. The resident was found to have medical conditions unrelated to staff neglect, and staff were properly trained to meet residents' needs.
Report Facts
Facility capacity: 66
Census: 48
Staff training attendance: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-03-14 regarding staff response to resident calls, toileting needs, timely medical attention, and staff training.
Complaint Details
The complaint included allegations that staff did not respond to resident calls for assistance, did not meet resident toileting needs, failed to seek medical attention in a timely manner, and were not properly trained. The investigation found these allegations to be unfounded based on interviews with residents, staff, and review of incident and hospital records.
Findings
After extensive interviews, file reviews, and observations, all allegations were found to be unfounded. Staff responded appropriately to resident calls, met toileting needs, sought timely medical attention, and were properly trained.
Report Facts
Falls detected: 14
Median response time: 74
Average response time: 103
Response within 5 minutes: 92.31
Capacity: 66
Census: 44
Medication training hours: 8
Hands-on shadowing hours: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Phoebie Carcot | Administrator | Facility administrator mentioned in report header |
| Deborah Taylor | Met with Licensing Program Analyst during investigation | |
| S1 | Medication Technician Trainee | Employee who completed medication training and shadowing |
| S2 | Medication Technician Trainee | Employee who completed medication training and shadowing |
| S3 | Medication Technician Trainee | Employee who completed medication training and shadowing |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 66
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were mismanaging resident medication.
Complaint Details
The complaint was substantiated. The allegation involved staff mismanaging resident medication, specifically missed doses of Levetiracetam for resident R1 on April 25 and 26, 2024. The Health and Wellness Director was unable to explain discrepancies in medication administration records.
Findings
The investigation found the allegation to be substantiated based on file review showing missed medication doses for resident R1. However, no deficiency was cited as the facility had been previously cited for a similar allegation.
Report Facts
Facility capacity: 66
Resident census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Phoebie Carcot | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 66
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not provide showers, did not ensure residents were kept clean, and did not provide transportation services to residents in care.
Complaint Details
The complaint investigation was triggered by allegations that staff failed to provide showers, ensure cleanliness of residents, and provide transportation services. After investigation, all allegations were determined to be unfounded, meaning the allegations were false or without reasonable basis.
Findings
Based on interviews, file reviews, and observations, all allegations were found to be unfounded. Residents were provided showers as scheduled, staff assisted with cleaning residents after meals, and transportation services were arranged through third parties or family members when the facility bus was unavailable.
Report Facts
Shower frequency: 9
Shower frequency: 8
Facility capacity: 66
Resident census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Phoebie Carcot | Administrator | Facility administrator interviewed during investigation |
| Deborah Taylor | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 66
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2024-06-10, including resident not receiving medication, resident death due to neglect, staff dropping resident during transfer, and staff falsifying resident records.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident was not receiving medication as prescribed. The allegation that a resident died due to neglect was unfounded. Allegations that staff dropped a resident during transfer and falsified resident records were unsubstantiated.
Findings
The investigation substantiated the allegation that a resident did not receive medication as prescribed, posing a potential health and safety risk. The allegation that a resident died due to neglect was found to be unfounded. Allegations that staff dropped a resident during transfer and falsified resident records were unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Licensee did not comply with CCR 87465(a)(4) requiring assistance with self-administered medications, as a resident was not administered medications as prescribed.
Report Facts
Capacity: 66
Census: 46
Plan of Correction Due Date: Feb 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Deborah Taylor | Facility representative met during the investigation | |
| Davina Barker | Administrator | Facility administrator named in the report |
Inspection Report
Census: 44
Capacity: 66
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
The visit was an unannounced case management visit conducted by Licensing Program Analyst Cassie Yang to review facility compliance and request training documents for staff S1 and S2 for 2023 and 2024.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst requested copies of specific staff training documents to be provided by the end of the day via email.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Administrator/Director | Met with Licensing Program Analyst during the case management visit. |
| Cassie Yang | Licensing Program Analyst | Conducted the unannounced case management visit and requested training documents. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 66
Deficiencies: 1
Date: Dec 23, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations of facility staff's lack of care and supervision resulting in a resident sustaining serious bodily injury and another resident's death.
Complaint Details
The complaint was substantiated. Allegations included lack of care and supervision leading to serious bodily injury and death of residents. The investigation found staff failed to intervene during an altercation between residents, violating facility protocols. An immediate civil penalty of $500 was assessed.
Findings
The investigation substantiated that staff failed to follow facility protocols during an altercation between residents, resulting in one resident sustaining severe injuries and subsequent death. Staff did not intervene or redirect as required, posing an immediate health and safety risk.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs by staff sufficient in numbers, qualifications, and competency, as staff failed to follow protocol during an incident involving aggressive resident behavior.
Report Facts
Civil penalty amount: 500
Capacity: 66
Census: 34
Plan of Correction due date: Dec 24, 2024
Plan of Correction due date: Jan 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation and signed report. |
| Phoebie Carcot | Administrator | Facility administrator during the investigation. |
| Deborah Taylor | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 66
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that facility staff served expired food to residents.
Complaint Details
The complaint was substantiated based on evidence that facility staff served expired food to residents. The allegation was validated by a preponderance of the evidence standard.
Findings
The investigation substantiated the allegation after a kitchen inspection revealed expired food items, including Hollandaise Sauce Mix and peanut butter, in the facility's dry pantry storage. The Executive Director confirmed the presence of expired salad dressing, which was properly disposed of prior to the inspection.
Deficiencies (1)
Failure to comply with CCR 87555(a) General Food Service Requirements; expired food items were found in the pantry posing potential health, safety, and personal rights violations to residents.
Report Facts
Facility capacity: 66
Census: 31
Plan of Correction due date: Oct 4, 2024
Expired food items observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Administrator / Executive Director | Met with Licensing Program Analyst during investigation |
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Monitoring
Census: 29
Capacity: 66
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The visit was an informal conference conducted virtually to discuss pending open investigations and staffing concerns at the facility.
Findings
The Department agreed to monitor the facility and required proof of staff training on personal rights of residents. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Executive Director | Met during the informal conference and named as facility representative. |
| Anthony Perez | Licensing Program Manager | Present during the informal conference and named as Licensing Program Manager. |
| Cassie Yang | Licensing Program Analyst | Present during the informal conference and named as Licensing Program Analyst. |
| Lyndee Whaley | Regional VP of Operations | Facility representative present during the informal conference. |
| Phil Altman | Senior VP of Operations | Facility representative present during the informal conference. |
| Kim Eldridge | Regional Director of Health & Wellness | Facility representative present during the informal conference. |
| Holly McMurray | Senior VP of Care & Compliance | Facility representative present during the informal conference. |
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee denied a resident's hospice worker entry to the facility.
Complaint Details
The allegation was that the licensee denied a resident's hospice worker entry to the facility. Interviews revealed the hospice nurse was not denied entry but was requested by the facility not to return, and the hospice agency complied. The allegation was determined to be unfounded.
Findings
The investigation included extensive interviews and concluded that the allegation was unfounded. The hospice nurse was not denied entry; rather, the facility requested the hospice nurse not return after observations during a visitation. No deficiencies were cited.
Report Facts
Facility capacity: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Deborah Taylor | Executive Director | Met with Licensing Program Analyst during investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 66
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The visit was an unannounced case management inspection conducted due to a reported unusual incident involving a resident being threatened by a staff member to stop using the call light.
Complaint Details
The complaint was substantiated as the investigation confirmed the incident where staff member S1 threatened resident R1, violating personal rights and causing fear.
Findings
The investigation confirmed that staff member S1 threatened resident R1 to stop using the call light, causing fear in the resident. S1 was suspended and is no longer employed at the facility. The facility notified appropriate authorities and parties about the incident.
Deficiencies (1)
Violation of CCR Title 22, Section 87468.1 Personal Rights of Residents in All Facilities: Resident was threatened by staff to stop using call light, causing fear and posing an immediate health and safety risk.
Report Facts
Capacity: 66
Census: 27
Deficiencies cited: 1
Plan of Correction Due Date: Jul 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the inspection and investigation |
| Deborah Taylor | Executive Director | Met with Licensing Program Analyst during inspection |
| Davina Barker | Administrator | Facility administrator present during inspection |
| Anthony Perez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 66
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to an unusual incident/injury report involving a resident choking during lunch.
Complaint Details
The visit was triggered by a LIC 624 Unusual Incident/Injury Report. The incident was substantiated with appropriate follow-up actions including notification of the responsible party and diet modification.
Findings
The incident involved a resident choking on meat which was dislodged by staff, followed by evaluation and a diet change. No deficiencies were cited during the visit.
Report Facts
Capacity: 66
Census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Taylor | Executive Director | Met with Licensing Program Analyst during inspection |
| Davina Barker | Regional Director | Met with Licensing Program Analyst during inspection and discussed incident |
| Cassie Yang | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 22
Capacity: 66
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance using the full care tool.
Findings
The facility was found to be in substantial compliance with no deficiencies cited. The environment was clean, sanitary, in good repair, and residents were observed engaged in activities. Files reviewed were complete and liability insurance was current.
Report Facts
Residents on hospice services: 8
Care staff on AM and PM shifts: 3
Med tech on AM and PM shifts: 1
Care staff on night shift: 2
Perishable food supply: 2
Non-perishable food supply: 7
Facility temperature: 72
Resident files reviewed: 5
Personnel files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Davina Barker | Executive Director | Met with Licensing Program Analyst during inspection and reported staffing information |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 22
Capacity: 66
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
The visit was an unannounced post-licensing inspection conducted to complete the required annual inspection process.
Findings
The inspection found no citations or deficiencies. The Licensing Program Analyst met with the Executive Director and explained the purpose of the visit. The report was generated to clear the post-licensing inspection in the system.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Davina Barker | Administrator/Executive Director | Met with Licensing Program Analyst during inspection. |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 66
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not notify the responsible person of an increase in monthly rent rates.
Complaint Details
The complaint alleged the facility failed to notify the responsible person of an increase in monthly rent rates. The investigation found that a letter of Annual Care Level Rate Adjustment Notice was provided on October 31, 2023, with an effective date of January 1, 2024, and a subsequent letter informing of a rent increase effective June 1, 2024. The responsible party had signed updated service plans and was properly notified. The allegation was concluded as unfounded.
Findings
The investigation included file reviews and interviews, revealing that the facility had provided proper notification of rent increases and care level adjustments. The allegation was found to be unfounded with no deficiencies cited.
Report Facts
Capacity: 66
Census: 22
Care service cost Level 1: 2550
Additional care level cost: 600
Rent increase amount: 341
Initial care assessment total: 590
Updated care assessment total: 940
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Davina Barker | Executive Director | Met with Licensing Program Analyst during the investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 66
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
The visit was an unannounced case management inspection conducted on 06/12/2024 regarding an incident report received on 06/11/2024 involving a resident's fall.
Complaint Details
The visit was triggered by a complaint involving a welfare check by local law enforcement on 06/10/2024 due to a recent fall of resident R1. The incident was under review at the time of the visit.
Findings
The inspection found that the resident had a 'guided fall' on 06/03/2024 with no injury sustained and no hospital visit. The incident report LIC624 was not submitted as it was considered not a fall. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Davina Barker | Administrator | Met during the inspection and involved in discussion of the incident. |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection visit. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 66
Deficiencies: 0
Date: May 16, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations received on 2022-11-16 regarding staff conduct and facility operations.
Complaint Details
Allegations investigated included staff shoving a pill into a resident’s mouth, failure to assist resident into bed, staff violating resident’s privacy by listening to conversations without consent, and signal system not operational. All allegations were found to be unsubstantiated or unfounded.
Findings
The investigation included interviews, record reviews, and facility observations. All allegations were found to be either unsubstantiated or unfounded due to lack of preponderance of evidence or false claims.
Report Facts
Capacity: 66
Census: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Middleton | Memory Care Director | Met with during investigation and exit interview |
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report as overseeing licensing program |
Inspection Report
Annual Inspection
Census: 16
Capacity: 66
Deficiencies: 0
Date: Apr 26, 2023
Visit Reason
The visit was an unannounced Required-1 Year Inspection conducted to evaluate the facility's compliance with health and safety regulations using the CARE Inspection Tool.
Findings
The inspection found the facility to be in compliance with no deficiencies cited. The environment was clean and safe, medications were properly stored and administered, and staff training was up to date.
Report Facts
Residents' files reviewed: 5
Staff records reviewed: 5
Fire extinguisher last serviced: Mar 1, 2023
Hot water temperature: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassiana Bush | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Wendy Middleton | Memory Care Director | Participated in facility tour during inspection |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 16
Capacity: 66
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff do not ensure the facility is free from bed bugs.
Complaint Details
The complaint alleged that staff do not ensure the facility is free from bed bugs. The investigation included interviews and record reviews, and the complaint was found to be unfounded.
Findings
The investigation found that although bed bugs were observed in the facility on 12/19/2022, the facility took all necessary steps to relocate the resident, treat the infestation with pest control professionals, and continues monthly pest control services. Therefore, the allegation was determined to be unfounded.
Report Facts
Facility capacity: 66
Census: 16
Complaint control number: 25-AS-20230123162212
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Wendy Middleton | Memory Care Director | Met with Licensing Program Analyst during investigation and exit interview |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 66
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 09/22/2022 regarding staff mishandling a resident's personal items and the resident's room being in disrepair.
Complaint Details
The complaint was investigated and found to be unfounded.
Findings
The investigation determined that the alleged allegations occurred prior to the licensure of the facility and do not apply to the current licensee. The complaint was found to be unfounded, meaning the allegations were false, could not have happened, or lacked a reasonable basis.
Report Facts
Capacity: 66
Census: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Tracy Lehner | Administrator | Met with Licensing Program Analyst during investigation |
| Adebimpe Ekundare | Named as Facility Administrator |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 66
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility is not issuing a refund.
Complaint Details
The complaint was investigated and found to be unfounded.
Findings
The investigation determined that the alleged allegations were prior to licensure of the facility and do not apply to the current licensee. The complaint was found to be unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis.
Report Facts
Capacity: 66
Census: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Tracy Lehner | Administrator | Met with Licensing Program Analyst during the investigation |
| Adebimpe Ekundare | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 66
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the facility was not following quarantine protocol and that the administrator was not present at the facility.
Complaint Details
The complaint alleged that the facility was not following quarantine protocol and that the administrator was not present at the facility. Both allegations were investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Findings
The investigation found both allegations to be unfounded. The facility was following all required COVID-19 positive protocols, including quarantine measures and staff training. The administrator was present at the facility for an adequate number of hours and fulfilled her responsibilities.
Report Facts
Capacity: 66
Census: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tracy Lehner | Administrator | Met with the Licensing Program Analyst during the investigation and was involved in the exit interview |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Original Licensing
Census: 39
Capacity: 66
Deficiencies: 0
Date: May 17, 2022
Visit Reason
An unannounced pre-licensing visit was conducted due to a change of ownership at the facility.
Findings
The facility was toured and inspected, including resident rooms and common areas. The facility meets licensing requirements and no deficiencies were noted.
Report Facts
Number of shared rooms: 28
Number of private rooms: 10
Number of full bathrooms: 4
Number of dining areas: 2
Number of television rooms: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adebimpe Ekundare | Executive Director | Met with Licensing Program Analysts during the inspection and toured the facility |
| Lavinia Muscan | Licensing Program Analyst | Conducted the unannounced pre-licensing visit |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced pre-licensing visit |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 43
Capacity: 66
Deficiencies: 0
Date: Apr 27, 2022
Visit Reason
The visit was conducted as part of a change of ownership application process for the facility.
Findings
The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adebimpe Ekundare | Participant in COMP II interview | |
| Malissa Acuna | Administrator | Facility administrator verified during interview |
| Jude De La Concepcion | Licensing Program Manager | Named in report header |
| Bethany Hunter | Licensing Program Analyst | Named in report header and analyst signature |
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