Cogir of Brentwood

Allegation investigated: Facility overcharged Resident

On 04/29/2026 at 9:48AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct an initial10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Jessica Depasquale, Executive Director (acting), and explained the purpose of visit. During the course of the investigation, LPA interviewed witnesses (W1, W2) and Staff (S1). LPA obtained the following documents: Resident (R1) admission agreement, facility’s staff schedule, residents’ roster, email thread between facility and W2, and facility invoice statement showing a refund check in the amount of $55.00 with check #17599 paid to W2 on 04/27/2026. Continue on LIC9099C..... Unsubstantiated Continued from LIC9099 Allegation: Facility overcharged Resident Interview with S1 revealed facility issued a check in the amount of $55.00, and the check was delivered to W2 by Federal Express (Fed Ex) priority overnight with a tracking number of #871114796786. Interview with W2 revealed check in the amount of $55.00 was delivered by Fed Ex and it was received on 04/48/2026. Record review revealed facility received knowledge of Fed Ex envelope arrived to W2 04/28/2026. Record review also revealed, Fed Ex delivered a package to W2's address with a tracking number of #871114796786 on 04/28/2026 at 10:30AM. Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 15-AS-20260420161002

Type of visit: Required - 1 Year

On 01/30/2026 at 9:30AM, Licensing Program Analysts (LPAs) T. Syess-Gibson and L. Hall, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with James Hall, Executive Director (ED) and explained the purpose of the visit. Administrator certificate #7014180740 expires:11/19/2027. Facility’s fire clearance was approved for 104 non-ambulatory, 40 ambulatory residents, and 6 bedridden residents. LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs observed a swimming pool behind a locked gate. LPAs toured apartments #124, #255 and #313. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the resident’s shared bathroom was measured at 113.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/29/2026. First aid kit was observed to be complete. Emergency Disaster Plan was last updated on 02/07/2025. Fire drill was last conducted on 12/17/2025. Continued LIC809C. Continued from LIC809 LPAs reviewed eleven (11) staff records and ten (10) residents records, and they were all complete. LPAs reviewed a sample of medication with Med Tech. LPA requested the following documents to be submitted to CCLD by 02/06/2026. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Updated Facility Sketch No deficiencies observed during visit. Exit interview conducted and a copy of this report provided to James Hall.the state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Case Management - Incident

On 03/26/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit in regard to an incident report. LPA met with Executive Director (ED), Cayia Peevy and Health and Wellness Director, Kuldip Singh. LPA explained the purpose of visit. Based on the incident report dated 03/21/2025, at around 5:30AM on 03/16/2025 staff responded to the emergency pull cord. Resident (R1) had an unwitnessed fall. R1 reported to staff that the fall happened in the living room of his apartment, he was able to get himself up and walk into his office and called for help, when R1 started to feel pain in right hip. Staff called 911 and R1 was transported to the hospital. During visit, LPA interviewed staff and reviewed R1’s file including physician's report and incident report. R1’s physician's report stated that R1 does not need assistance with transporting or ambulating. Interview with staff revealed that R1 sustained a broken right hip as a result of the fall and after right hip surgery R1 was admitted to skilled nursing facility on 03/19/2025. Staff also stated R1 was independent prior to fall and required no assistance with ambulating or ADLs, R1 is back in the community and has been very social, participating in activities and comes down for meals daily. No deficiencies sited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 26, 2025

Allegation investigated: -Resident (R1) developed stage 3 pressure injury while in care. -Staff do not assist resident (R1) with incontinence needs.

On this day, March 11, 2025, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to deliver findings for the above allegations. LPA met with Executive Director (ED) Cayia Henry and informed the reason for visit. During the course of investigation, the Department obtained copies of resident roster and staff schedule. Copies of the following resident records were also obtained: medical records, Resident Information and Contact Sheet; Resident Face Sheet; Admission Agreement; Pre-admission Appraisal; Service Plan; LIC602A Physician's Report; Unusual Incident Reports; facility notes; Home Health Visit notes. Staff (S1, S2, S3, S4, S5, S6, S7 and previous Executive Director) were interviewed on 9/28/23, 10/04/23, 10/12/23. R1’s family member (FM1) was also interviewed on 9/29/23, home health nurse (HHN) on 10/31/23, and residents (R2, R3, R4) on 10/04/23. ........continued on 9099C (page 2) Unsubstantiated Page 2 Allegation: Resident (R1) developed stage 3 pressure injury while in care. Medical records revealed that R1 was admitted to the hospital on 3/17/23 due to acute cholecystitis. R1 informed the nurse about having the pressure injury prior to being admitted to the hospital. R1 was developing a coccyx deep tissue pressure injury and was provided home health services when R1 was discharged back to the facility on 3/17/2023. The Department observed that the medical records do not indicate that R1 presented at hospital on 3/17/23 with a pressure wound. The medical records indicate that a developing wound was noted after hospital admission; that R1 was discharged back to the facility with Home Health orders; and that Home Health records noted progressive healing, and was healed at the time of Home Health discharge in June 2023. Interviews with S1, care staff and med-techs (S2, S3, S4, S5, S6 and S7) revealed consistent statements of R1 refusing to be transferred and requiring staff assistance to be transferred from R1’s recliner, bed, and toilet. Staff denied remembering that R1 had a stage 3 pressure injury. S1 denied knowing the stage of R1’s pressure injury despite HHN confirming that S1 saw R1’s pressure injury and was aware that R1’s wound was a stage 3. HHN visited R1 frequently and treated the pressure injury. HHN did not believe the facility staff contributed to R1’s pressure injury developing into a stage 3. R1’s pressure injury responded well to the treatment by HHN which healed by June 2023. HHN did not have any concerns regarding facility staff and care of R1’s pressure injury. Therefore, the allegation is unsubstantiated. Allegation: Staff do not assist resident (R1) with incontinence needs. Reporting party (RP) stated the night staff tell R1 to wet her bed instead of getting her up to the restroom. RP further stated that the morning staff stated they saw R1 had been sitting in her feces, and the night shift did not change her. Review of records showed FM1 brought up these issues to the previous ED. FM1 sent email to previous ED stating R1 was not refusing to go to the bathroom with the bedside commode and wanted the staff to ‘ignore’ R1 and get R1 up to toilet. .....continued on 9099C (page 3) Page 3 All staff stated R1 was a 2 person assist in transferring and would at times refuse care. S6 stated that R1 was a two person assist and needed assistance with getting from R1’s recliner to the bathroom. S6 also stated that R1 would page the caregivers for help every 2 to 3 hours, and when R1 did not page, S6 would still check to make sure R1 was okay. HHN stated R1 was clean every time HHN went to the facility. HHN did not have any concerns regarding the facility and indicated the staff provided adequate care to R1. R2 does not know R1. R2 expressed satisfaction with the care R2 was receiving at the facility. R3 denied knowing R1. R3 stated she’s not able to walk and has several disabilities that do not allow her to leave her bed and she gets the attention she needed from the care staff. R3 also stated she felt there weren’t any incidents where the care staff did not meet her needs. R4 stated knowing R1 but does not know about the care R1 was receiving from the staff. R4 stated she’s happy with the caregivers. The Department was not able to obtain information from R1. Therefore, the allegation is unsubstantiated. Based on records review, interviews, and the Department unable to obtain information from R1, the 2 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 15-AS-20230615163239

Type of visit: Required - 1 Year

On 02/06/2025 at 1:00PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and C. Fowler, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Cayia Henry Peevy, and explained the purpose of the visit. Administrator certificate #7020769374 expires: 02/25/2026. The facility’s fire clearance was approved for 104 non-ambulatory, 40 ambulatory and 6 bedridden residents. Facility has hospice waiver for twelve (12) residents. LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs observed a swimming pool behind a locked gate. LPAs toured apartments #117, #235 and #334. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/02/2025. First aid kit was observed to be complete. Fire drill was last conducted on 01/31/2025. Continued LIC809C. Continued from LIC809 LPAs reviewed five (5) staff records, five (5) resident record and they were all complete. LPA requested the following documents to be submitted to CCLD by 02/13/2025. · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan · Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Case Management - Incident

On 10/21/2024 at 2:23PM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived unannounced to conduct a case management visit regarding an incident report received on 10/16/2024. LPA met with Health and Wellness Director, Kuldip Singh and Davina Barker, Regional Executive Director. Incident report dated 10/16/2024 revealed that Resident 1 (R1) had an unwitnessed fall resulting in laceration to head and a fractured pelvic. LPA interviewed Staff one (S1) who stated Staff two (S2) contacted (S1) after responding (R1) pendant call at 10:30AM. LPA was not able to interview Resident 1 (R1) at the time of visit , resident is at skilled nursing facility due to pelvic fracture. LPA was not able to interview Staff two (S2) who was off of work during visit. Interview with Staff 1 (S1) revealed that resident (R1) informed both staff members of walking with walker out of the restroom in her apartment when she suddenly lost her balance and fell. (R1) hit her head on the cabinet resulting in head laceration. (S2) applied pressure on head laceration, stopping the bleeding before paramedics arrived. R1 was transported to the hospital by paramedics. S1 also stated (R1) isn't a fall risk and hasn't had any other incidents pertaining to falls. LPA collected the following documents: Incident report(s) for October 2024 and Resident roster, No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to Davina Barkerthe state’s words, verbatim · CDSS document, Oct 21, 2024

Type of visit: Required - 1 Year

On 2/20/2024 at 1:00PM, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Jeffrey Freeth, and explained the purpose of the visit. Administrator certificate #6062809740 expires 7/10/2024. The facility’s fire clearance was 104 non-ambulatory, 40 ambulatory and 6 bedridden residents. Facility has hospice waiver for 12 residents. LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs toured apartments #166, #260, #317, and #319. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/12/2024. First aid kit was observed to be complete. Fire drill was last conducted on 02/19/2024. Continued on LIC809C. Continued from LIC809. LPAs reviewed ten (10) staff records, ten (10) resident record and vehicle maintenance log. LPA requested the following documents to be submitted to CCLD by 02/27/2024. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance LPA observed the following deficiencies: At 3:35pm, LPAs observed during record review majority of staff were not first aid or CPR certified. At 3:40pm, LPAs observed during record review several staff did not have a health screening or TB test on record. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy the appeal rights and the report provided.the state’s words, verbatim · CDSS document, Feb 20, 2024

Type of visit: Case Management - Incident

On 12/14/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a resident incident that occurred on 12/1/23. LPA spoke with Kuldip Singh, Health and Wellness Director and explained the purpose of the visit. LPA received an unusually incident report (UIR) regrading a resident had an un-witnessed fall during happy hours led to a fracture hip. Resident had hip surgery and is in a skill nursing for recovering. Kuldip spoke with resident daughter on 12/4/23 to get updates on resident. LPA interviewed Kuldip regrading the follow up with the resident current condition. Resident is currently at the rehab recovering, and while return after facility do an evaluation. Prior to the fall resident was very independent, self-care, and self-med with no assisted devices. LPA obtained: Staff roster, resident roster, resident progress notes, and a copy of the incident report that faxed to CCLD on 12/5/23. No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 14, 2023