Cottages At Hemet

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not make sure residents have their dinner. Staff left residents in soiled bedding or briefs. Staff did not make sure resident’s restroom was clean. Staff dd not answer resdients call pendants in a timely fashion.

Licensing Program Analyst (LPA) Nicol Weslety conducted an unannounced complaint visit to investigate the above allegations. LPA Wesley met with Community Relations Director Brittney Walsh to explained the purpose for todays visit. Brittney included Resident Service Director Miajoy Mc Elyea to join the visit. The investigation consisted of the following: LPA toured the community, obtained copies of staff roster, client roster, faciltiy menu, tested residents call buttons. LPA interviewed 8 out of 9 residents, and 5 staff. Regarding allegation: Staff did not make sure residents have their dinner. Dinner is served in each of cottages dining area at 4:30pm. A resident can eat in the dining area or in their room. When its time for dinner, the resident are told its dinner time and for those they are in a wheelchair and require assistance, they are taken the dining area. LPA Wesley interviewed 8 residents who said the staff makes sure they have their dinner. continued on LIC9099C. M Unsubstathe state’s words, verbatim · CDSS document, May 10, 2025 · control 18-AS-20240118084146

Allegation investigated: Facility issued a rate increase for a falsiflied change of condition Facility falsified paperwork

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Barbara Bogoje Resident Service Director and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 05/07/2024, LPA Delgado interviewed one (1) staff and requested and obtained copies of documentation. During today’s visit LPA Gutierrez interviewed Resident Service Director/Administrator, staff #1- Staff #3 and resident #2 -resident #9. Resident one R1 has left facility. LPA obtained copies of the following documents: staff roster, resident roster, R1’s admission agreement, physicians reports, identification and emergency information, and resident assessment. SEE LIC 9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20240503151502

Allegation investigated: Staff are not providing adequate food service to residents Staff speak inappropriately to residents in care Staff are not providing adequate supervision to resident

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Barbara Bogoje Executive Director/Administrator and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 09/26/2022, LPA Colvin interviewed one (1) staff and requested and obtained copies of documentation. During today’s visit LPA Gutierrez interviewed Executive Director/Administrator, staff #2- Staff #4, and resident #2 -resident #9. LPA toured kitchen and obtained copies of the following documents: staff roster, resident roster, food menu, R1’s admission agreement, physicians reports, and appraisal needs and service plan. SEE LIC 9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20220923153215

Allegation investigated: Facility staff dropped resident during a transfer resulting in bruising. Facility did not notify resident's family of incident. Facility did not seek timely medical attention for resident. Staff did not dispense medication according to doctor’s orders.

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced subsequent complaint investigation visit on 04/19/2025 regarding the above allegations to deliver findings. LPA Ramirez conducted subsequent complaint investigation on 3/29/25; interviews were conducted and a needs further investigation was required. LPA Delgado conducted initial complaint visit on 10/20/2023 and a needs further investigation was documented. The investigation consisted of the following: LPA Ramirez requested copies of Resident#1 (R1)- face sheet, emergency contact information, Centrally Stored Medications (LIC 622), Controlled Medications Record, Prescription Orders for R1, Physician’s Report (LIC 602), Unusual/Incident Reports for R1, Hospice care notes, Resident Assessment for R1, Interview of Resident# 2- 8 (R2-R8), Interview of Staff#1- 5 (S1-S5), Attempted Interview of R1, Attempted Interview of Staff#6 (S6), Copies of S6’s: employment application, separation form, CPR/First Aid certificathe state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20231013131810

Allegation investigated: Staff do not ensure residents’ incontinence needs are met. Staff do not respond to resident's call button. Staff intimidated resident. Staff spoke to resident in a disrespectful manner.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Brittney Walsh – Sales Director/Community Relations Representative and the reason for the visit was explained, shortly after Executive Director/Administrator Barbara Bogojie arrived to assist with visit. The investigation consisted of the following: LPA obtained copies of staff and client rosters, toured facility, observed incontinence supplies, tested residents call buttons, and interviewed 9 residents and 4 staff. (continued on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20241002122520

Allegation investigated: Staff do not respond to requests for assistance in a timely manner. Staff do not ensure that resident's toileting needs are being met while in care.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Brittney Walsh – Sales Director/Community Relations Representative and the reason for the visit was explained, shortly after Executive Director/Administrator Barbara Bogojie arrived to assist with visit. The investigation consisted of the following: LPA obtained copies of staff and client rosters, toured facility, observed incontinence supplies, tested residents call buttons, and interviewed 9 residents and 4 staff. (continued on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20240109155246

Allegation investigated: Resident sustained injuries due to a fall Staff leave residents unattended in dirty diapers for extended periods of time Staff mismanage residents' medication Staff failed to treat residents with dignity and respect Staff do not ensure that residents are hydrated Staff handle residents in a rough manner Facility is unkempt

*This report supersedes report dated 4/5/25 to correct documents information and dates for R2's records on LIC 9099C.* On 4/5/25 Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Nidia Chavez Activities and explained the reason for the visit. The investigation consisted of the following: On 3/26/25 LPA Flores requested a copy of staff/resident roster over the phone. On 4/2/25 LPA requested documents for three residents over the phone. On 4/4/25 LPA conducted a visit at the facility interviewed administrator, 5 staff, 8 residents, and 1 staff over the phone. LPA toured the facility with Annette Harris concierge and observed 7 random resident room and common areas. LPA reviewed files for Resident #1-2(R1-R2) and requested copies of Physician’s Report, Identification and Emergency Information sheet, Needs and Care plan, medical records. (CONTINUED ON LIC 9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 7, 2025 · control 18-AS-20221221141339

Allegation investigated: Resident sustained injuries due to a fall Staff leave residents unattended in dirty diapers for extended periods of time Staff mismanage residents' medication Staff failed to treat residents with dignity and respect Staff do not ensure that residents are hydrated Staff handle residents in a rough manner Facility is unkempt

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Nidia Chavez Activities and explained the reason for the visit. The investigation consisted of the following: On 3/26/25 LPA Flores requested a copy of staff/resident roster over the phone. On 4/2/25 LPA requested documents for three residents over the phone. On 4/4/25 LPA conducted a visit at the facility interviewed administrator, 5 staff, 8 residents, and 1 staff over the phone. LPA toured the facility with Annette Harris concierge and observed 7 random resident room and common areas. LPA reviewed files for Resident #1-2(R1-R2) and requested copies of Physician’s Report, Identification and Emergency Information sheet, Needs and Care plan, medical records. LPA requested copies of incident reports and medication destruction logs for the past three months, medication training for 2 medication technicians(Med-Tech), personal rights training, trthe state’s words, verbatim · CDSS document, Apr 5, 2025 · control 18-AS-20221221141339

Allegation investigated: 5Staff are not mitigating the spread of scabies in the facility.

Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up visit to deliver findings for the allegation above. LPA met with Brittany Walsh, the Sales Director, and explained the reason for the visit. The investigation consisted of the following: On 11/13/24, LPA Stephanie Martinez conducted the initial visit. LPA interviewed a staff, requested copies of relevant documentation, and toured two of six buildings. It was determined the allegation needed a further investigation. On 4/4/25, LPA Chan conducted interviews with the administrator, 5 staff and 9 residents. The investigation revealed the following: Allegation – Staff are not mitigating the spread of scabies in the facility. The administrator and staff interviewed stated there was an outbreak of scabies in November 2024. They stated they took action right away to prevent the spread to other residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 5, 2025 · control 18-AS-20241105103403

Allegation investigated: Facility staff subjected resident to multiple doctor visits due to staff refusing to accept physician diagnosis. Resident sustained an injury from an unwitnessed fall due to lack of supervision. Facility staff did not notify resident’s authorized representative of resident’s injury. Facility is not reporting contagious outbreak to residents and/or their authorized representatives.

Licensing Program Analyst (LPA) Cynthia Chan conducted a follow-up visit to deliver findings. LPA met with Staff, Brittany Walsh, and explained the reason for the visit. The investigation consisted of the following: On 12/19/24, LPA Stephanie Martinez started the complaint investigation and interviewed one staff, requested copies of relevant documentation, and toured two of six buildings. The allegations needed a further investigation. On 4/4/25, LPA Chan conducted a follow-up visit to interview the administrator, 5 Staff, and 9 residents. Resident #1 is no longer residing at the facility and was not interviewed. The investigation revealed the following: Allegation - Facility staff subjected resident to multiple doctor visits due to staff refusing to accept physician's diagnosis. It is alleged that the staff kept insisting Resident #1 (R1) had scabies. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 5, 2025 · control 18-AS-20241210124228

Allegation investigated: Staff did not administer resident's medication as prescribed.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/29/2025 regarding the above allegation. LPA Mixon conducted initial complaint visit on 01/13/2023 and a needs further investigation was documented. During today’s visit, LPA Ramirez was greeted by Staff-Brittney Walsh and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 5 interviews (S1 – S5), Attempted interview of Resident#1 (R1) Resident#2-9 interviews (R2-R9), copies of Resident#1 (R1)- face sheet, emergency contact information, Centrally Stored Medications (LIC 622), Controlled Medications Record, Prescription Orders for R1, Physician’s Report (LIC 602), and physical plant tour. See 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 29, 2025 · control 18-AS-20230110093308

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained an unstageable pressure injury while in care Resident sustained injuries resulting in hospitalization due to unwitnessed fall(s) while in care Staff did not notify responsible party of resident's change in condition

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to deliver findings. LPA Seo Jeon met with Barbara Bogoje, Administrator, and explained the purpose of the visit. The following allegations were investigated by the Department, the investigation included interviews and record review. It was alleged that resident sustained an unstageable pressure injury while in care. On 02/08/2022 Resident#1 (R1) was transported to the hospital and admitted for a fall. Medical records were reviewed. Medical records dated 02/08/2022 do not indicate any pressure injuries noted. Based on facility records, on 02/21/2022, staff called 911 for R1. A review of facility records titled Narrative Charting was completed. The Narrative Charting dated 02/21/2022 indicated R1 was sent out via 911 due to self-harm. While at the hospital, R1 was diagnosed with a pressure injury. A review of medical records dated 02/21/2022 revealed R1 was diagnosed with a wound. Continued on LIC9099-C Uthe state’s words, verbatim · CDSS document, Feb 26, 2025 · control 18-AS-20220722151836

Allegation investigated: Facility staff are not ensuring resident is thoroughly cleaned Facility staff are not assisting resident with toileting Resident does not have pendant/call button Resident is not provided assistance in a timely manner

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegations noted above. LPA met with Executive Director Barbara Bogoje and explained the purpose of the visit and the elements of the allegation. The allegations were investigated, which consisted of observations, interviews and records review. On February 22, 2022, Community Care Licensing received a complaint alleging that facility staff are not ensuring resident is thoroughly cleaned, facility staff are not assisting resident with toileting, resident does not have pendant/call button and resident is not provided with assistance in a timely manner. Regarding the allegation of facility staff are not ensuring resident is thoroughly cleaned. It was alleged that Resident #1 (R1) was observed to be covered in feces while at an appointment in or around March 2022. Interview conducted with R1 revealed that R1 believes they are given “the red-carpetthe state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20220222133113

Allegation investigated: Facility is in disrepair

Licensing Program Analyst (LPA) Abdoulaye Zerbo made an unannounced follow-up complaint visit to the facility to deliver findings on the above allegations. LPA met with Executive Director (ED) Barbara Bogoje, explained the purpose of the visit, and was granted entry into the facility. It was alleged that the facility is in disrepair. All six (6) cottages, including the kitchen area, were toured during the inspection. The kitchen was observed to be clean and fully functional. Five (5) of the six (6) cottages were in good condition. One cottage in memory care had a hole in the ceiling in the laundry room. Maintenance and the Executive Director (ED) acknowledged the issue and confirmed that repairs were underway. Based on the evidence, the allegation mentioned above is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the preponderance of the evidence standard has been met. Deficiencies were cited on an LIC9099- D page. Substantiatedthe state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20250109093446

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff disclosed confidential medical information of resident to an unauthorized party.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Executive Director (ED), Barbara Bogoje, and informed her of the purpose for the visit. A report was received by the Department alleging Staff One (S1) provided Resident One's (R1's) medical information to an unauthorized family member on 10/03/2024. The LPA conducted staff interviews, reviewed records, and obtained copies of relevant documentation. R1 was not available for an interview prior to the delivery of the investigation findings. S1 was interviewed and reported the individual, who was the alleged unauthorized family member, has visited R1 at the facility on at least one occasion. S1 denied providing the individual with R1's medical information. The LPA interviewed the alleged unauthorized family member; the individual reported they have visited with R1 on occasion and were denied medical information about R1the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 18-AS-20241210124228

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident fell while in care

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Continuous Improvement Specialist Kim Henson and explained the purpose of the visit. Regarding allegation “Resident fell while in care”, it was reported Resident One (R1) had fallen while in care due to lack of supervision by staff and sustaining an injury as a result of the fall. Interview with staff revealed Staff One (S1) observed R1 in the living room in their wheelchair. S1 returned to the living room from the kitchen and found R1 on the floor. S1 attempted first aid to the back of the head and contacted two (2) staff for assistance. Records review of staff schedule revealed two caregivers and one MedTech were scheduled to work the PM shift on 08/11/2021. Records review of facility’s Narrative Charting revealed R1 sustained a laceration to the back of the head and R1 was transported to the hospital. R1 was admitted to the fathe state’s words, verbatim · CDSS document, Aug 5, 2024 · control 18-AS-20210816150952

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility does not have hot water

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to initiate an investigation into the allegation list above. LPA met with Executive Director (ED), Marc Pacia and explained the purpose of the visit. LPA interviewed three (3) staff, three (3) residents, toured the facility, and obtained copies of pertinent documents. On September 26, 2023, Community Care Licensing received information which stated the facility did not have hot water.” It was reported that Aspen Cottage at the facility was without hot water for approximately three (3) weeks from September 13, 2023 to September 26, 2023. Interviews conducted revealed the facility's hot water heater could not be repaired but need to be replaced. As a result, Rooms 1-8 (CONTINUED ON LIC9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Sep 28, 2023 · control 18-AS-20230926082804

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.