Cogir of Brea.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct a Case Management Visit. LPA was greeted and granted entry by the Concierge at 1pm. LPA met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. The purpose of the visit is to amend a licensing report (LIC 9099) from April 28, 2026. An exit interview was conducted and a copy of this report and amended report were provided.

(Continued from LIC 9099) Per Physician's Report dated 8/20/2025, Resident #1 (R1) has primary diagnoses of osteoporosis and osteoarthritis. R1 does not have mental cognitive impairment but has a history of behavior expression of paranoia. R1 is independent and does not require assistance with mobility/ambulation. Per medical assessment the resident is non-ambulatory due to physical condition diagnoses. R1 is capable of administering their own medications. The pre-appraisal from 8/11/2025 states R1 doesn't prefer to be social but is encouraged to join activities. R1 is capable of doing their own laundry and household tasks. Per R1's Care Plan R1 has a history of occasional anxiety and depression or mood disorder. It was alleged that: Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others. Per LPA staff and resident interviews, R1 usually comes to the dining room for dinner. A comment was made, at the dinner table that female residents stink. Another resident at the table then covered their nose. R1 felt the comment was made towards them. LPA interviewed six of six residents. Three residents at the table were interviewed. One resident confirmed the allegation, a second resident denied the allegation and the third resident moved out of the community and could not be interviewed. Two additional residents were interviewed and denied the allegation. The allegation that Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others is Unsubstantiated. LPA investigated the allegation that Staff do not ensure resident is provided personal privacy. Staff were instructed to conduct a room check for a resident's missing laundry. Two staff members knocked on R1's door and requested entry. The staff stated they were looking for a resident's missing laundry items and requested permission to look in R1's closet and dresser. R1 permitted entry to search for the missing items. R1 does not use laundry services and is able to do their own laundry. Several days later, R1 shared the incident with management, stating they were not afforded privacy and that the staff members entered while R1 was in the bathroom. Staff and management are aware that R1 prefers to be private and so staff will enter the apartment in pairs as needed, to ensure R1 is more at ease with staff. R1 is independent and does not require a lot of services and staff do not enter R1's apartment often. One resident confirmed the allegation and three residents denied the allegation. The allegation that Staff do not ensure resident is provided personal privacy is Unsubstantiated. (Continued on LIC 9099-C1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099-C) It was also alleged that Staff do not ensure resident is spoken to in an appropriate manner. It was reported to management that two persons entered R1's apartment and were asking questions about R1's medications and medical information. The incident occurred on a Saturday and management was not aware of the incident until Monday. Management interviewed staff and reviewed facility hallway cameras. It was determined the two people visiting were a Physician's Assistant (PA) and Social Worker (SW) from the Primary Care Provider agency; whom R1 permitted entry. R1 also reported that another staff member made inappropriate comments while watching an evening movie. When asked what the comments were, R1 referred to a film the staff member was discussing. The staff member has since resigned and left the community. One resident confirmed the above allegation and three residents denied the allegation; stating staff are always professional and courteous. Five of five staff interviewed all denied the allegation. Thus the allegation that staff do not ensure resident is spoken to in an appropriate manner is Unsubstantiated. LPA investigated the allegation that: Staff do not ensure resident is served meals in a timely manner as a form of punishment. It was reported to LPA that dining staff did not provide a meal at dinner to punish the resident. LPA interviewed five of five staff members who denied the allegation. Three of five residents interviewed also denied the allegation. One resident was unavailable to interview who were present. Staff interviews shared that R1 had eaten an entree and, later, ordered another entree. The server took the second entree order but, as the staff member was walking to the kitchen, was delayed by another table. The order was then placed with the chef. As the residents at R1's table received their initial dinner orders, one of the residents inquired about the second order for R1. The server stated the order was placed but R1 immediately got up from the table and left the dining room. This was brought to management's attention and the chef spoke with R1 about the incident and assured R1 it was not a delay to punish the resident and the order was completed. Thus the allegation that Staff do not ensure resident is served meals in a timely manner as a form of punishment is Unsubstantiated. (Continued on LIC 9099-C2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099 C1) Based on LPA's file review, observations and interviews the allegations that: Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others, Staff do not ensure resident is provided personal privacy, Staff do not ensure resident is spoken to in an appropriate manner and, Staff do not ensure resident is served meals in a timely manner as a form of punishment are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director (ED) Cynthia Figueroa and a copy of this report,and LIC 811 were provided to the facility. ***This is an amended report.***

(Continued from LIC 9099) LPA also entered three of three resident rooms in Assisted Living (AL). All beds were made and three of three residents interviewed shared they do not sit in soiled linens and that they do not have any issues with laundry services. If there are issues with accidents, care staff call housekeeping and sheets are laundered. Apartments are all cleaned once per week which includes laundering linens Thus this allegation is Unfounded. It was alleged that the Facility is malodorous. LPA toured Assisted Living (AL) and Memory Care (MC) and did not detect any foul odors. LPA randomly checked six of six resident apartments and there were no odors detected. Six of six residents and nine of nine staff all denied the allegation that there were foul odors. It was also alleged that Staff do not ensure facility is clean and sanitary. Upon touring the facility LPA observed bathrooms in common areas being cleaned and the facility was clean and sanitary. Six of six residents and nine of nine staff all denied that the staff do not ensure the facility is clean and sanitary. LPA obtained housekeeping and laundering schedules and all apartments are cleaned once a week. Thus the allegations that the Facility is malodorous and that Staff do not ensure facility is clean and sanitary is Unfounded. It was also alleged that Staff mishandled residents resulting in staff dropping residents. LPA interviewed six of six residents and nine of nine staff members who all denied this allegation. LPA reviewed Unusual Incident Reports submitted to licensing by the facility and there are no occurrences of residents being dropped. Thus, the allegation that Staff mishandled residents resulting in staff dropping residents is Unfounded. LPA investigated the allegation that Staff do not ensure residents are provided a comfortable environment. LPA interviewed six of six residents and nine of nine staff. All residents and staff felt supported by the management and stated staff ensure that residents are provided a comfortable environment. LPA toured the facility and conducted a health and safety check and there were no issues with staff providing a comfortable environment. LPA reviewed three of three staff files and all training of staff are current. Thus, the allegation that Staff do not ensure residents are provided a comfortable environment is Unfounded. Lastly, LPA inquired if Staff do not ensure hazardous items are inaccessible to residents. LPA toured the facility and did not encounter obstacles obstructing pathways, hazardous materials or sharps and knives that (Continued on LIC 9099-C1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099-C) were accessible to residents in Assisted Living or Memory Care. LPA toured the activities area in Memory Care and noted markers were secured in a box that was inaccessible to residents. Glue sticks are rarely used but are secured in the Lifestyle Enrichment office. LPA interviewed six of six residents and nine of nine staff who all denied this allegation. Thus the allegation that Staff do not ensure hazardous items are inaccessible to residents is Unfounded. Based on LPA's record review, observations and interviews, the allegations that: Staff do not ensure that residents' have clean bedding, Facility is malodorous, Staff do not ensure facility is clean and sanitary, Staff mishandled residents resulting in staff dropping residents, Staff do not ensure residents are provided a comfortable environment and Staff do not ensure hazardous items are inaccessible to residents are Unfounded. The allegations are false, could not have happened, and/or are without a reasonable basis. An exit interview was conducted with Executive Director, Cynthia Figueroa, and a copy of this report and LIC 811 was provided to the facility.

(Continued from LIC 9099) LPA interviewed three of three alert residents regarding their finances and if there were any issues with the facility and financial abuse. Three of three residents denied the allegation and stated there were no problems with billing at this time. LPA interviewed one witness. The witness also denied the allegation and had no knowledge of financial abuse of the residents. LPA interviewed Executive Director (ED) regarding Omnicare medications received for R1 while R1 was out of the community from July 19, 2025. R1 transferred to a higher level of care and medications received for that cycle were destroyed, per community protocol. A new cycle of medications was ordered in September, in anticipation of R1's return to the community, but R1 did not return and passed away on September 18, 2025. Per ED, the September medications were also destroyed. ED will work with Omnicare to handle the medication costs incurred while resident was not in the community. After discussion regarding Long Term Care Insurance, ED reviewed insurance claim filed and found the clerical error for July 12, 2025. ED confirmed the correct date should be July 19, 2025 and that the facility will resubmit the claim to insurance. ED will provide written documentation to the Responsible Party regarding the financial issues reported to the Licensee to ensure all parties are on the same page. ED also provided this documentation to the LPA via email Based on LPA's record review and interview, the allegation that Licensee financially abused resident is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Executive Director (ED), Cynthia Figueroa, and a copy of this report and LIC 811 was provided to the facility.

(Continued from LIC 9099) 2024. Needs and Services Plan noted R1 had Moderate toileting needs and required stand-by assistance for toileting tasks. The hospice nurse documented on January 3, 2025 that resident was incontinent with a strong urine odor. Antibiotics were prescribed for a Urinary Tract Infection. On January 5, 2025 the Needs and Services Plan was updated by the Health and Wellness Director (HWD). Toileting needs changed from Moderate to Extensive, stating R1 required hands-on assistance from one person and the resident is incontinent. HWD spoke with hospice and family that a personal caregiver would help with R1s behaviors. Facility progress notes, beginning on December 16, 2024 report R1 was resistant to being directed to the toilet, would remove pull up and frequently urinated or had bowel movements in common areas. Facility staff worked with hospice to find ways to mitigate these behaviors. The allegation that Staff did not meet a resident’s incontinence needs is Unsubstantiated. It was alleged th at Staff did not have planned activities for the residents. LPA obtained Activities Calendar for Assisted Living (AL) and Memory Care (MC), also known as Revere, with Daily Activities detail by the hour for February and March 2025. LPA observed there were six to seven scheduled activities per day. LPA toured Revere on March 18, 2025 and observed four residents painting shamrocks that were continued from a St. Patrick’s Day activity on March 17, 2025. LPA interviewed two of two Activities staff regarding the implementation of activities. One staff member works Sunday through Thursday and the other works Tuesday through Saturday. There are only three days where both activities staff are present. Of the three days when both are present, one staff member usually drives residents for scheduled appointments as needed. Interviews shared that if an activities staff member needs to drive, the staff member will start the activity and leave instructions for care staff to complete with residents. Four of the seven days per week there is only one activities person on-site. (Continued on LIC 9099C1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099C) Both activities staff reported that, if residents are uninterested in participating in Activities, that they do not force them and will pivot to try to engage the residents in another way. LPA interviewed four of four residents in Revere. One of the four residents participated in activities. Three of four residents did not show interest in participating. Due to staffing shortages activities staff were pulled to assist with non-care needs; such as serving food or answering calls. Staffing shortages were cited on May 13, 2025 Control number 22-AS-20250509094345 . Thus, although activities were always planned, staffing dictated if they could be implemented. Therefore the allegation that: Staff did not have planned activities for the residents is Unsubstantiated. It was alleged that Staff mishandled a resident’s personal belongings due to R1’s soiled clothing being thrown out. LPA interviewed two of two housekeepers who reported they are responsible for cleaning resident rooms, once per week, or as needed. Per interviews with two of two housekeepers, care staff are responsible for laundering resident personal belongings. LPA interviewed four of four med technicians and three of three care staff. Interviews with three of three Revere care staff stated that when a resident’s clothing is soiled, most times staff discover the resident throws the clothing away in trash cans, attempts to flush soiled clothing in toilet, hides soiled clothing in furniture or places item in another resident’s room. Care staff denied tossing R1’s clothing and that staff make the effort to clean the resident and launder the clothing. Facility progress notes on December 20, 2024 documented R1 was aggressive towards staff and another resident and was removing and taking their belongings. When staff were asked for three items of R1’s clothing that were missing, the staff member who stated the soiled clothing was thrown away denied the allegation. Thus, the allegation that: Staff mishandled a resident’s belongings is Unsubstantiated. (Continued on LIC 9099C2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099C1) It was alleged that a Resident sustained an unexplained injury while in care. Photo evidence was submitted to the Department of the bruise under the chin. Facility progress notes dated January 7, 2025 at 7:49am reported the Med Tech (MT) had changed R1 and had given morning medications when MT noticed bruising on the bottom of R1’s jaw. It was reported to the Health and Wellness Director and hospice. Hospice notes dated January 8, 2025 documented that nurse reported the bruise under R1’s chin and the skin was intact. Family was notified by facility of the bruise. Med Tech was unaware of how R1 received the bruise and there were no falls reported. The unexplained bruise was immediately identified and reported to the Health and Wellness Director, Hospice nurse and family. Thus the allegation that a resident sustained an unexplained injury while in care is Unsubstantiated. It was alleged that Staff did not properly report incidents involving a resident. Review of facility progress notes from January 11, 2025 stated R1 had a fall in the dining area during lunch time and was witnessed by care staff. The fall happened approximately at 11:15 am and Med Tech (MT) charted at 1:37:02 pm that the spouse was called twice but MT was unable to leave a voicemail due to the voicemail box being full. On the third try MT texted information to spouse’s cell phone. Charting notes stated the daughter was also called and was unable to get a hold of her, but an incident report was made. MT also notified hospice and spoke to the nurse. MT spoke to Manager on Duty (MOD) that MT attempted to contact family. At 12:23pm MOD left a voicemail for family to call the community. The voicemail also references other items to address with family but does not state that R1 was sent out per facility policy. R1 was transported via ambulance to a local hospital for further evaluation. On January 11, 2025 at 9:30pm progress notes stated resident moved out this evening and meds were signed out and given to family. The allegation that Staff did not properly report incidents involving a resident is Unsubstantiated. (Continued on LIC 9099C3 ) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099C2) It was alleged Staff did not ensure a resident was properly fed while in care due to R1 not being fed at the scheduled meal times. Per R1’s physician report dated December 12, 2024, R1 was diagnosed with Alzheimer’s disease and is able to feed themselves. Per R1’s initial Needs and Services Plan dated December 16, 2024 , R1 required minimal assistance and that R1 could feed self, chew and swallow food, however needs reminding/ cueing to maintain adequate intake. LPA conducted interviews with six of six staff who reported their priority is assisting residents who require feeding. Staff interviewed reported R1 often would remain in their bed due to being awake most of the night. Due to staffing needs, they had to first assist with residents who were present in the dining area and required feedings. Staff frequently checked on R1 and would attempt to coax R1 to eat. Per Pre-Appraisal dated December 15, 2024 food allergies were noted, R1 does not eat lunch and eats small portions. Review of facility progress notes reported R1 often would remain in their bed during scheduled meal times. Med Tech charted on December 16, 2024 that R1 stated they were not hungry. R1 was given water and propel powder provided by family. Family was aware R1 did not always eat. Notes report on December 18, 2024 R1 refused dinner and chose to eat two cookies. On December 22, 2024 R1 ate with family member but only at three to four spoonfuls of dinner. It is noted that spouse said this was the normal eating pattern. Family stated that if R1 refuses to eat, to provide Ensure or pudding. On December 24, 2024 R1 refused to eat and spouse was made aware. On December 30, 2024 R1 ate 100 percent of dinner. On January 6, 2025 R1 ate 80 percent of dinner. Hospice notes reviewed dated December 15, 2024, documents R1's wandering behavior, separating themselves from others; and refusing eating and medications. On December 20, 2024, Hospice notated that R1 continued to have a decline in appetite. On December 30, 2024 Hospice noted a weight loss of eight pounds. Hospice nurse met with HWD and MT to discuss ways to increase R1’s appetite. (Continued on LIC 9099C4) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099C3) Based on record review and interviews staff continued to coax R1 to eat and charted Food and Nutrition in the progress notes. Staff communicated with hospice nurse that R1 did not like to eat and that they always attempted to feed R1 or offer Ensure. Staff did frequent checks on R1 due to behaviors. R1 continued to refuse to eat and hospice and family were aware. Thus the allegation that Staff did not e nsure a resident was properly fed while in care is Unsubstantiated. It was alleged staff did not have adequate recording keeping of a resident due to facility not documenting R1’s weight daily. Per R1’s hospice weight records reviewed, R1 was weighed on December 15, 2024, to weigh 116 lbs. R1’s physician report dated December 12, 2024 further corroborated R1’s weight at 116 lbs. LPA conducted interviews with three of three staff that facility policy is to weigh residents once per month or as pr

(Continued from LIC 9099) LPA interviewed two of two staff regarding the procedure for cooking chicken and how staff determine the chicken is cooked. Dining Service Director/ Chef stated chicken is considered cooked when the food thermometer measures the temperature at 165 degrees for fifteen seconds. LPA toured the kitchen and observed line staff checking temperatures of food items being cooked. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation that the: Resident is getting sick due to staff not cooking food thoroughly is Unsubstantiated. An exit interview was conducted with Cynthia Figueroa, Executive Director, and a copy of this report and LIC 811 was provided to the facility.

(Continued from LIC 9099) The Department conducted a ten day visit on October 15, 2024 and observed approximately forty residents in the dining room for dinner. Due to staff shortages in Memory Care, Memory Care residents were brought to dinner in the dining room. Three of four resident interviews denied the allegation that:Facility fails to provide a safe environment for its residents. Thus is allegation is Unsubstantiated. LPA obtained standing modified diets from the kitchen and spoke to the Chef about resident allergies and preferences. Chef shared the line staff know resident preferences and they are posted in the kitchen. During the time the complaint was received, Chef was not an employee but currently, modified diets are followed. Three of four residents interviewed stated they did not have issues with food at this time. Seven of seven resident Physician Reports and modified diets were reviewed and were being followed. None of the residents reported having allergies or becoming ill from food. Thus the allegation that: Facility staff is not following dietary orders is Unsubstantiated. LPA reviewed seven of seven Physician's Reports (LIC 602A) and spoke with ED Figueroa regarding alcohol policy for Memory Care. Currently two residents are allowed alcohol per LIC 602A but the majority of residents in Memory Care get a non-alcoholic alternative during Happy Hours. Thus, the allegation that: Alcohol is being served to residents with a dementia diagnosis is Unsubstantiated. Four of four residents were asked if the facility safeguards their personal information. Three of four residents felt personal health information was safeguarded. One of four residents felt staff spoke about other residents' health issues. Nine of nine staff denied that resident personal information was improperly shared with others. Based on resident and staff interviews, the allegation that Facility staff does not safeguard the residents' personal information is Unsubstantiated. Upon touring the facility. LPAs visited resident rooms and took temperatures in common areas. The temperature ranged between 72.3 - 74.1 degrees Fahrenheit. Three of four residents did not have any issues with temperature in their apartments and one of four residents received a partial refund due to an AC unit in disrepair. Thus the allegation that: Climate control is not operational is Unsubstantiated. (Continued on LIC 9099C1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued fro LIC 9099C) LPA reviewed resident files and spoke to former ED regarding residents being admitted that need a higher level of care. Former ED stated on May 12, 2025 that Title 22 Regulations are clear about what diagnoses can or cannot be accepted. Residents who have a change of condition, such as falls, are reassessed with a new Needs and Services Plan, an updated Physician's Report and a care plan meeting. The allegation that: Facility is admitting residents requiring a higher level of care and supervision is Unsubstantiated. LPA spoke with nine of nine staff, the ED and Life Enrichment Director regarding transportation services. LPA reviewed the October 2024 Activities Calendar, the Concierge and Transportation Log and obtained a Bus Repair Invoice. The community bus' wheelchair lift was not operable and had been inspected and then repaired. Both the Life Enrichment Director and Assistant were designated drivers during this time and the Transportation log does show residents were taken to appointments in the month of October 2024. Thus the allegation that: Transportation services included in the admission agreement are not being provided to the residents is Unsubstantiated. Although the allegations 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 allegations that: Facility fails to provide a safe environment for its residents, Facility staff is not following dietary orders, Alcohol is being served to residents with a dementia diagnosis, Facility staff does not safeguard the residents' personal information, Climate control is not operational, Facility is admitting residents requiring a higher level of care and supervision and Transportation services included in the admission agreement are not being provided to the residents are Unsubstantiated. An exit interview was conducted with Cynthia Figueroa, Executive Director and a copy of the report and files reviewed (LIC 811) were given at the time of the visit. ****This is an amended report.****

(Continued from LIC 9099) LPA toured the facility and was permitted entry in Resident #1 (R1's) apartment by Care Staff. LPA conducted six of six staff interviews, three of three witness interviews and interviewed the Executive Director (ED regarding the incident that occurred on Saturday, July 19, 2025. LPA reviewed documents and noted on the Appraisal, Services Plan and Physician's Report that Resident #1 (R1) is independent and only requires assistance with medication. Although R1 does not receive alert charting care for two hour checks, staff continually check on R1; especially if R1 strays from the normal routine. R1 keeps to self and felt the frequent checks were not necessary and wears a bracelet call button. R1 is able to toilet and bathe independently and when staff inquire if R1 needs assistance, R1 does not request assistance. R1 rarely presses the bracelet pendant and was not wearing it at time of fall. On the date of the unwitnessed fall, R1 was found by AM Medical Technician (Med Tech) when entering the apartment to give medications at 8:30am. Responsible Party and Emergency Medical Services (EMS) were immediately called and R1 was transported to a local hospital for evaluation. R1 was admitted to the hospital for further observation. It was reported by AM Med Tech to EMS that R1 received meds at 8pm. ED also observed R1 the day before and did not note anything unusual and observed R1 playing Bingo. PM Med Tech did not notate any changes in condition in charting. Photo documentation was obtained and staff members on-site, at the time of the incident, noted the urine and feces were fresh and that R1 had not been left for an extended period of time. Record review did not show that Resident #1 (R1) has had any falls since admission on April 10, 2025. The incident on July 19, 2025 was the first fall for the resident in the community. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations that: Facility left resident unattended for an extended period of time and Facility did not provide care and supervision resulting in multiple falls are Unsubstantiated. An exit interview was conducted with Executive Director (ED) Cynthia Figueroa and a copy of the report was provided to the facility.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to amend a report from a complaint visit on June 18, 2025. LPA was greeted and granted entry by the Concierge. LPA met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit. LPA amended the resident identifier from R3, on the second page of the report, to R6; to match the correct resident from the Confidential List of Names (LIC 811) provided to the facility on June 18, 2025. An exit interview was conducted with ED Figueroa and a copy of the amended report was provided to the facility.

Licensing Program Analyst (LPAs) Rose Ruppert and Hanna Gough arrived at the facility to conduct the required annual inspection and was greeted and granted entry by staff. LPAs met with Administrator (AD) Cynthia Figueroa and explained the purpose of the visit. The facility currently has fifty four residents in care. The facility is a two-story building with a memory care unit, resident apartments, kitchen, great room, activity room, dining room, lobby, staff offices, medication room and an outdoor shaded seating area for resident use. LPAs observed the kitchen to be clean and free of vermin. LPAs observed the seven day non-perishable and two day perishable food supply on hand. LPAs observed the emergency food and water supply in a storage room. LPAs observed all resident apartments had the required components and furnishings. LPAs observed the water in resident bathrooms to be tested between 112.6-117.3 degrees Fahrenheit. LPAs observed the knives to be stored in the locked chef office when not in use making them inaccessible to residents in care. LPAs observed the centrally stored medication to be in the locked medication rooms made inaccessible to residents in care. LPAs observed toxins and chemicals to be locked and stored in the housekeeping rooms located on each floor and made inaccessible to residents in care. LPAs observed the outdoor space to be free of obstructions. LPAs observed the delayed egress in the memory care unit to be operational. LPAs observed an outdoor shaded space for resident use in the memory care unit. LPAs observed residents engaged in bingo and a resident council meeting during the course of the visit. LPAs observed the last fire drill conducted on June 4, 2025. LPA observed the last fire inspection done on October 16, 2024 for the entire facilities fire and sprinkler systems. LPAs observed resident medication and no discrepancies were observed. Continue on LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 809) LPA reviewed XXX of XXX staff training and fingerprint records. [Insert any relevant details]. LPA reviewed XXX of XXX resident records . (OR) LPA conducted a complete review of resident and staff records. Client P&I records were reviewed and were accurate. LPA interviewed alert clients/residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on XXX 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPAs reviewed resident files and no discrepancies were observed. LPAs reviewed staff files and observed that the ED that has been overseeing the facility for three weeks is updating the files to completion. A technical advisory was given at the time of inspection. Based on today's inspection no citations are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Cynthia Figueroa and a copy of this report was left at the facility at the time of inspection.

(Continued from LIC 9099) A care plan meeting was held with facility representatives and R1’s family on May 20, 2025 and the decision was made not to move R1 to the facility memory care unit at this time and to remove R1’s motorized vehicle. R2’s physician report dated December 08, 2024, lists R2’s diagnosis as Mild Cognitive Impairment and intermittent bladder incontinence. Furthermore, the physician report states R2 is not able to care for their own toileting needs. Interviews conducted with five of five facility staff and six of six residents reported concerns that R2 was exhibiting incontinence issues in the facility creating sanitary issues in facility common areas. On April 15, 2025, the facility conducted a re-assessment of R2 and determined R2 required extensive 1:1 hands on assistance with incontinence care. Per interview with Executive Director, the facility had a care plan meeting on April 15, 2025 with R2’s family and assessed not to move R2 to the facility memory care unit at this time. Following the re-assessment of R2 interviews with residents reported the sanitary concerns had improved. It was alleged staff does not have job training or experience in the job assigned to them due to facility Chef overseeing the facility care floor. During LPA’s interview with Executive Director it was reported the facility Health and Wellness Director and Memory Care Director were not actively working at the facility beginning approximately May 8, 2025. Due to staffing shortages, the facility requested the facility Chef to assist with manager oversight over facility care floor staff. LPA conducted interview with Executive Director and facility Chef who both reported Chef’s role in overseeing the facility care floor was to provide managerial support to facility care staff. Both denied Chef was providing any direct care to facility residents and/or giving directions to facility care staff regarding care to residents. LPA reviewed facility training records for Chef. Per records reviewed facility Chef has current updated training in all mandatory training topics including but not limited to Dementia, Ladder Safety, Fire Safety, Customer Service, Home Health, Sexual Harassment, Diversity, Spiritual Aging, Hiring, Active Shooter, and Hospitality. Interviews with eight of ten staff reported no concerns with Chef’s oversights. Two of ten staff reported concerns with the Chef’s oversight of facility care floor as he needed to remain in his area of expertise. Interviews with nine of nine residents reported no concerns. Per interviews with facility Executive Director the facility is actively hiring for the facility Health and Wellness Director position as well as Memory Care Coordinator. Effective May 13, 2025, the Facility Regional Nurse is on site providing oversight to facility care (Continued on LIC 9099-C1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 9099C) floor. The facility has created a managerial schedule to ensure a manager is on site every day including weekends. Based on LPA's observation, interviews and record review, the Department has determined that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegations that the: Staff did not conduct proper appraisals to place residents in memory care and Staff does not have job training or experience in the job assigned to them are Unsubstantiated. An exit interview was conducted with Erin Hernandez, Community Relations Director and verbally read to Executive Director Cynthia Figueroa, and a copy of the report andthe List of Confidential Names (LIC 811) was provided to the facility.

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit regarding a report received in our Regional Office. LPA was greeted and granted entry by Concierge. LPA met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit. The purpose of the visit is to follow-up on a Death Report received in our office on May 22, 2025. LPA spoke with ED and obtained copies of Resident #1 (R1)'s: Identification Form, Physician Orders for Life Sustaining Treatment (POLST), Physician's Report, Needs and Services Plan/ Appraisal, Discharge paperwork from hospital and follow-up orders. LPA interviewed the Resident Services Director (RSD) from a sister facility; who was on-site with the MedTech, who were called to R1's apartment on May 22, 2025. Both Med Tech and RSD did not detect a pulse. 911 was called and RSD grabbed POLST paperwork and noted R1 was DNR. LPA spoke with ED about the chronological order of events; as well as with the Power of Attorney (POA). POA shared palliative care was being considered with Primary Care Physician (PCP) on the day prior to R1's passing. POLST documentation states Do Not Resuscitate (DNR) but the box was also checked for Full Treatment. At time of incident, RSD showed police department (PD) the POLST and verbally stated R1 was DNR and pointed at the checked DNR box. PD felt a faint pulse and initiated CPR and pointed to the POLST form box that was selected for Full Treatment. Paramedics arrived on scene and were told R1 was DNR and contacted POA, who also confirmed R1 was DNR. The Fire Department (FD) spoke with ED Figueroa regarding the communication between the facility, PD and FD and will provide an in-service for facility staff (Continued on LIC 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC 809)\ regarding clear and preferred communication for first responders. Based on LPA's file review, interviews and observations, the facility is in complaince with Title 22 California Code of Regulatiosn and no deficiences will be cited on this date An exit interview was conducted with Cynthia Figueroa, ED and a copy of this report and LIC 811 was provided at exit.

It is alleged staff files do not have the required documentation. Staff files are kept electronically and were made available to LPA. LPA reviewed 10% of hired staff at the facility and observed that all required documentation was in the files per title 22 requirements. It is alleged staff do not have criminal record clearance. LPA obtained an employee roster for the facility. LPA reviewed staff files, and it was observed a Criminal Record Clearances was in staff files. LPA cross checked the roster to the Guardian background check system and observed all hired onboard staff were associated to the facility and cleared. It is alleged staff do not have the required qualification. LPA reviewed 10% of the onboard hired staff files and observed that all required qualifications were met such as a medical assessment and training. It was observed that records reviewed reflected this paperwork and kept in the files per title 22 requirements. It is alleged staff do not respond to residents’ calls for assistance in a timely manner. LPA conducted a facility visit on January 21, 2025, and toured the physical plant of the facility. Upon the tour LPA entered several resident apartments, common spaces, and restrooms and tested the pull cord system. LPA observed that facility utilizes a pull cord system as well as pendants. LPA observed that the response time for staff to respond to calls were between 2 minutes and 15 minutes throughout the various times call system was pulled. On today’s visit LPA toured the facility and observed residents being assisted by caregivers. Records review for call system for assistance logs reflect all alerts and reflect that the response time is anywhere between 50 seconds to average response time of 16 minutes 28 seconds. It is alleged that facility staff are not providing adequate food service. LPA conducted a site visit on January 21, 2025, and on today’s visit. LPA toured the facility kitchen and bistro; it was observed that there was sufficient amount of quality and quantity of perishables and nonperishable food for residents. At the time of visits LPA observed food being prepped and staff preparing the food for resident meals. LPA obtained a copy of the facility weekly menu for review, and the always available menu and observed the food service to be well balanced with variety of choices. LPA conducted interviews with the facility Executive Chef and stated that food delivery is twice a week, and Saturdays as needed. Residents have the choice to modify the menu Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 to their liking as well as food being modified based on resident needs. Dining room services is from 7:00am to 7:00pm and after 7:00pm the bistro will be stocked with food and will be available to residents at all times of the day. Interview with facility residents 7 of 7 indicated that they didn’t have an issue with the food served and they have always been able to request food or request for something out of the menu and the bistro always has food for them. Tour of the dining room LPA observed food being served, menu posted, and always available menu posted. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at facility.

It was reported by ED Kara that the elevator did work but made a noise that was concerning. ED reported the elevator was "down" for 2 weeks until a technician could check the elevator. ED stated on 2/7/2025 a technician came to the facility to fix the noise issue in the elevator. Per review of work order Schindler Elevator Corporation "lubed rails" and elevator was opened back up for use by 1:50pm on 2/7/2025. Regarding the allegation facility is understaffed. Per review of caregivers/med-tech schedule there are 5 staff members in the AM shift which is 6am-2:15pm, 4 staff members in the PM shift which is 2pm-10:15 and 2 staff members during NOC shift which is 10pm to 6:30 am for Assisted Living. Per interviews with 4 out of 4 residents state they feel all their needs are met and they have enough staff. Therefore based on the preponderance of evidence through records review and interviews the allegations that facility is not in good repair and facility is understaffed are determined to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility did not safeguard resident's personal belongings , the following has been concluded: Based on interviews and records reviewed, multiple incidents of theft or loss are alleged to have occurred on the premises. Most of the incidents came to be known to facility staff knowledge after being mentioned during the facility's residents council. Reports were made to local law enforcement and did not result in additional investigation after an officer was initially dispatched. Records review also confirmed that no cash amounts were placed into the facility's safeguarding authority. Additionally, facility staff provided LPA with a file where all theft and loss incidents were logged including: a description of the article, its estimated value, the date and time the theft or loss was discovered, if determinable, the date and time the loss or theft occurred as well as the action taken. The facility's theft and loss policy is also posted on the premises as required. All elements of the required theft and loss policy are therefore present. Regarding the allegation that Facility has surveillance cameras in the resident's room , the following has been concluded: Based on a tour of the physical plant, LPA was able to confirm the presence of a video surveillance system operated by the licensee, restricted to the facility's common areas. A review of multiple residents' admission agreements show the following clause which implies approval prior to admission: " For security purposes, there are video cameras in some of the common areas of Cogir of Brea. These cameras are not monitored by staff. By signing this Agreement, you consent to the use of video surveillance in the common areas. In order to protect the dignity and privacy of our residents, we do not permit the use of nanny cams or other video surveillance devices in resident apartments without written approval. " Individual agreements for both residents observed to have video cameras in the room reviewed and signed by respective responsible parties. No additional cameras found during a tour of a total of thirteen randomly selected units throughout the facility. Regarding the allegation that Facility is not in good repair , the following has been concluded: Based on two tours of the facility physical plant and observation of a total of thirteen units on both levels in addition to the common areas, no outstanding items of disrepair were observed by LPA and/or facility staff. Additionally, maintenance working orders were reviewed and residents interviews conducted. No outstanding items of maintenance were identified at the time of the present visit. Based on the evidence gathered, all three allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with the Health and Wellness Director Miriam Im and explained the reason for the visit. During the required 10-day visit to begin the investigation into complaint # 22-AS-20240502115044, LPA observed that the See Something, Say Something poster (PUB 475) was not posted in the main entry way of the facility. The PUB 475 poster was posted in the hallway adjacent to the main entry way of the facility next to the mail boxes and elevator. LPA informed the Health and Wellness Director that the PUB 475 poster must be posted in the main entry way of the facility. The Health and Wellness Director stated she understood. An exit interview was conducted and a copy of the report provided.

Licensing Program Analyst (LPA) Lydia Martinez conducted an announced Pre-Licensing visit and was greeted and granted entry into the facility by Designated Administrator Samuel Faye. The initial Application to operate an Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 04/12/2023 for a capacity of 110 non-Ambulatory residents, of which 12 may be bedridden. A tour of the physical plant was conducted inside and out with Mr. Faye. The following was observed: No resident were present during today's visit as facility is a brand new facility. Structure: The facility is designed as an apartment Assisted Living and Memory Care with two floors with a restaurant style kitchen/food prep area, Lobby, Activity Room/Art Studio, Bistro, Medication Room, Movie Theater, Fitness Room, Beauty Salon, Dining Room, and a Courtyard with patio tables and chairs. The resident’s bedrooms are spacious and will easily accommodate the residents furnishings. Air/Heating: Central air/heating system installed with a central panel to control each designated section of building. Resident’s bedroom have individual central panel to control entire apartment. Bedrooms Residents: 58 in Assisted Living and 22 in Memory Care for total of 110 non-Ambulatory residents. All bedrooms are equipped with an attached bathroom. Signal System: Call system is in place in each apartment in Assisted Living and Memory Care. Was tested and found to be operational. Bedrooms Staff: No bedroom designated for awake-staff. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Bathrooms: All bathrooms have a working toilet, wash basin, grab bars and walk-in shower. Linens & Hygiene Supplies: Adequate supply of new linen available in storage space of facility. Ombudsman Poster, Personal Rights and See Something Say Something Poster: Ombudsman poster, Personal Rights and See Something Say Something posters were posted. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review and Emergency Disaster Plan with means of exiting and emergency phone numbers listed. Evacuation Chairs are in place. Menus posted and available. Menus prepared one week prior and listed for food served for one week. Generator: O bserved during the visit. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables will be available at all times when residents present. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired and tested by outside vendor. Appliances: Residents apartment are equipped with a refrigerator/freezer and microwave. Toxins: Several locked closets for storage of toxins and cleaning equipment. Water Temperature: Is within regulatory requirements of 105 and 120 degrees F. Medications, First-Aid Kit & Book: Medication, First Aid kit, and First Aid book stored in medication room, inaccessible to residents. Resident & Staff Files : Records will be kept in business office. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Pool/Jacuzzi & Pets: No pool or bodies of water observed. Pets will be allowed under 30 lbs. Fire Extinguisher: Mounted in hallways and common areas. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents use, commensurate with the Plan of Operation. Fire clearance: Granted on 06/07/2023 for 98 non-Ambulatory, and 12 bedridden residents. The following special conditions shown on the approved floor plan: Approved delayed egress and bedridden occupants. Bedridden not to exceed 12 for entire building. Component III: Component III is waived as Applicant is an existing Administrator. Designated Administrator was notified that the final application approval will be issued by CAB in Sacramento. The facility meets Title 22 requirements and is ready to be licensed based on LPA's inspection. Exit interview was conducted and a copy of this report will be sent to email on file.