Cogir of Vallejo Hills

Allegation investigated: Ice machine is unsanitary

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a 10-day complaint investigation and deliver findings regarding the above allegations and met with Executive Director, Richard Breitkreutz. LPA made observations, gathered documents, and conducted interviews. Ice machine is unsanitary – Reporting Party (RP) alleges that facility ice machine has visible mold growth and is not being properly cleaned/sanitized. Review of submitted photographs showed an ice machine with visible black staining coming into contact with ice cubes. A further image indicates an Ice Machine Cleaning Log from Cogir of Vallejo Hills dated 2026 with no entries from January to current. Interviews with management indicated that a new log is being used to log staff cleaning and ice machine receives quarterly professional cleaning from a third-party company. Further interviews with management indicated that there was build up reported on upper interior portion of ice machine that is separated from the ice basin by a covering. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interviews with staff indicated that during a cleaning, staff noticed dark flakes and removed the plate separating the upper portion of the machine from the ice and noticed the build-up. Management was immediately notified and took the machine out of commission, removed and disposed of all the ice, and purchased bags of ice for use. The third-party contracted to clean the machine was contacted and took the machine apart for a thorough cleaning and sanitization. During this, management discovered that the third-party cleaners had missed a quarterly cleaning which may have led to the build-up in the top portion of the machine not normally accessible to staff. Cleaning was conducted same day, however, machine was kept out of commission for several days and bagged ice was used to ensure sanitization. LPA observed the ice machine to be clean with no build-up. Management removed the plate separation and LPA observed that the top portion of the machine was also clean and free of build-up. Review of cleaning logs indicated that some cleanings are being marked, however, management indicated staff occasionally forget to sign log. Review of third-party invoices and field reports indicate visits to check ice machine in July, August, and September of 2026. 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 is unsubstantiated. No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 21-AS-20260902164445

Allegation investigated: Staff member worked while under the influence of alcohol/drugs impairing their ability to provide adequate care and supervision, which presents a risk to resident.

At approximately 11:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Health and Wellness Director, Allison Mendoza, and Executive Director, Richard Breitkreutz. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Staff member worked while under the influence of alcohol/drugs impairing their ability to provide adequate care and supervision, which presents a risk to resident." Complaint alleged the following: Staff Member 1 (S1) comes into work under the influence of alcohol and drugs "all the time" and stated that S1 is unable to provide care and supervision to residents because they are intoxicated. Complaint further stated this has been ongoing since S1 started working at the facility 1 ½ to 2 years ago and that S1 “can barely stand up”. Continued on LIC9099C Unfounded Continued from LIC9099 Review of Facility staff schedule for January and February 2026 and facility's LIC500 (Personnel Report) indicated that S1 was hired in a job role that does not provide care and assistance to assisted living residents. Review of S1's file confirmed that they are not in a direct care position that provides assistance to residents and therefore does not work directly with them. Review of documents showed that S1 primarily worked in the upper and lower levels of the building which were identified as Independent Living. LPA Felias conducted a walkthrough of the building and confirmed that only the middle building of the campus was for assisted living residents while the upper and lower buildings were for Independent Living. It was observed that the buildings were connected by hallways. The Department was unable to determine if S1 appeared intoxicated in the presence of assisted living residents at the facility. Based on record review and observations made, this allegation is Unfounded. A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report discussed and provided to Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 21-AS-20260202164217

Allegation investigated: Staff does not ensure facility has 7 days of non perishable food on the premises

At approximately 11:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Health and Wellness Director, Allison Mendoza, and Executive Director, Richard Breitkreutz. During the course of the investigation, the Department conducted interviews, reviewed records, and made observations. The following allegation was investigated: “Staff does not ensure facility has 7 days of non-perishable food on the premises.” Complaint alleged the facility’s new kitchen staff discarded all non-perishable food, including emergency food supplies, resulting in the facility not maintaining the required 7-day supply. The Reporting Party (RP) reported the information was obtained from a staff member and expressed concern regarding emergency preparedness. LPA Deniz interviewed kitchen management, who reported older food items were discarded and new non-perishable items were ordered as part of inventory replacement. Continued on LIC9099C Unsubstantiated Continued from LIC9099 The pantry is in the process of being restocked. The facility receives food deliveries twice weekly. Invoices for newly ordered non-perishable food items were reviewed. On 03/02/2026, LPA Deniz toured the kitchen and food storage areas. The facility was observed to be clean and in good repair. LPA Deniz observed that the supply of non-perishable food items and emergency water supply appeared to meet the amount required by regulation. Based on observations, interviews, and record review, there is insufficient evidence to support the allegation that the facility failed to maintain a 7-day supply of non-perishable food. Therefore, the allegation is Unsubstantiated. A finding that the complaint allegation is unsubstantiated means 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. Exit interview conducted. Copy of report discussed and provided to Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 21-AS-20260226164349

Type of visit: Required - 1 Year

At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Business Office Manager, Denise Vasquez. Health and Wellness Director, Allison Mendoza, arrived during visit at approximately 9:30AM. Davina Barker, Regional Executive Director, arrived during visit at approximately 11:15AM. Facility is a Residential Care Facility for the Elderly (RCFE) and provides care and assistance to older adults. Facility has an approved fire clearance and capacity for 80 non-ambulatory residents and has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 166 residents in care with 52 residents in Assisted Living and 114 residents in Independent Living. LPA was also informed that there were 66 staff members on-site. LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed a sample size of 5 staff files and 5 resident files. Files were all found to be well organized, thorough, and contained the required documentation. Staff files had current First Aid and/or CPR certification and required annual training. Resident files were found to have updated resident assessments and appraisals. Facility's fire alarms were last inspected July 2025, facility's sprinkler systems were last inspected June 2026 and facility's fire extinguishers were last inspected December 2025. Facility's last emergency/disaster drill was December 2025. LPA discussed the following topics with Health and Wellness Director and Regional Executive Director: Reporting Requirements , PIN regarding 911 protocols, and Physician Reports (LIC602). During visit, LPA was informed that Administrator/Executive Director, Jose Barajas, was no longer at the facility and that Health and Wellness Director, Allison Mendoza, will be submitting their paperwork for Change of Administrator. Continued on LIC809C Continued from LIC809 LPA requested for the following documents to be submitted to Community Care Licensing (CCL) by 02/27/2026 for processing. Administrator Documents: · LIC 308 (Designation of Facility Responsibility) · Active and Current Administrator Certificate · First Aid Certificate · Administrator Resume · LIC 500 (Personnel Report) · LIC 501 (Personnel Record) · LIC 503 (Health Screening Report - personnel) · LIC215 (Applicant Information) · Proof of Negative TB test · Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) Requested Documents to update facility file: · Emergency Disaster Plan (LIC 610E) · Updated Liability Insurance · Copy of current Lease/Rental Agreement or Property Tax document showing control of property Documents to be submitted to Community Care Licensing (CCL) by due date of 03/12/2026. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 12, 2026

Allegation investigated: Staff is intoxicated while at work

At approximately 1:50 PM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Executive Director Jose Barajas. There is an allegation of Staff is intoxicated while at work. Complaint alleged that in February 2025, Staff Member 1 (S1) was observed to be intoxicated. Complaint stated that S1’s eyes and breath indicated their intoxication. Review of records showed that S1’s job role does not provide direct care to residents. Interview conducted with S1 stated that there were a few times they showed up to work hungover. S1 also stated that they have been sober since March 2025. Community Care Licensing staff also observed that S1 did not appear to be intoxicated or smell of alcohol during their interview. Interview conducted with Vice President of Operations, stated that they interact daily with S1 and have not observed them to smell of alcohol while at work. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interview conducted with Business Office Manager, stated that there was one incident in 2023 or 2024 where S1 showed up drunk to work but it was promptly addressed and S1 received treatment. The Department was unable to determine if S1 appeared intoxicated in the presence of facility residents. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegations are unsubstantiated means 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. No deficiencies cited, exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 21-AS-20250909132138

Type of visit: Required - 1 Year

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Susan Allen. Facility provides care and assistance to Older Adults in Assisted Living.. Fire clearance is approved for eighty (80) non-ambulatory residents. There is an approved hospice waiver for six (6) residents. The community consists of four buildings that are connected via walkways. One (1) building consists of assisted living. The other three (3) buildings are for independent senior living. The independent living buildings are not part of the Residential Care for the Elderly (RCFE) license. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Upon arrival, LPA was informed that there were 42 residents in care. At approximately 9:30 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:20 AM LPA toured the facility with ED Allen. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offered a variety of menu options for the residents at each meal. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of seven (7) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. The call system was tested in two (2) resident's rooms and Caregiver response time was under one (1) minute for both instances. Continued on 809-C ...Continued from 809 Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 9/2024. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged 1/20/2025. The Vallejo Fire Department inspected the facility on 4/30/2024 and issued no citations. The facility completes fire/emergency drills quarterly. LPA conducted a sample file review of eight (8) staff members. All staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for eight (8) residents. Upon review, LPA observed residents to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to residents in care. LPA conducted a spot check of five (5) residents’ medications and observed medications to be centrally stored and all documentation and medications to be in order. During the tour, residents were observed interacting with staff in common spaces, resting in their private apartments, participating in various activities and mingling amongst each other. The facility provides an eclectic range of activities for it's residents in assisted living. The facility has a hair salon, library and a country store. Computers are available for residents' use in the Library. Susan Allen’s Administrator Certification 6012927740 is current with an expiration date of 4/4/2026. LPA is requesting the following documents submitted to CCLD by 3/19/2025: LIC 500 - Personnel Report LIC 610E-Emergency Disaster Plan Copy of Current Liability Insurance No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Allen. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 19, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility's signal system is not working properly. Facility staff did not answer residents' calls in a timely manner.

Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of gathering additional information and delivering findings, regarding the above listed allegations. LPA met with Executive Director, Susan Allen, gathered additional statements and received copies of records. LPA also met with Saveiro Gratteri, Executive Chef who was authorized to sign reports at the end of the visit. It was alleged facility's signal system is not working properly. Investigation revealed there had been an issue with the front door phone not working properly after hours, when the main entrance door is locked and residents and/or family members who need to use the phone call system to alert staff to open the front door, or need assistance, has not been working. Residents have had to wait long periods of time. On a previous visit of 1/4/2024, Administrator explained they were working on the issue and purchased new phones and they were waiting to be installed. On todays visit, Administrator stated the front door system has been installed and new phones are operational, calls get directed to a cell phone that a staff member carries and there has been no further issues. Continue report see LIC9099-C Substantiated Continue report from LIC9099 In addition it was reported the call button pendant system was not working properly as staff were not always responding timely because the system at times would not go to the staff to respond. It was corroborated staff were not alerted when R1 pressed their pendant call button for assistance. Records show the call button was activated, but staff did not hear it. It was also alleged facility staff did not answer residents' calls in a timely manner in that when residents activate their call buttons during noc shift, a signal is sent to the front desk, however, the front desk was no longer staffed during the noc shift so no one heard it. It was also reported the noc shift staff wear pagers, however the residents’ calls do not go from the front desk to the pagers. It was corroborated resident R1 used their call button as they needed their PRN medication, staff were not responding and R1 had to leave their room to locate staff. Records show it has taken staff up to 32 minutes to respond to a residents call for assistance. Administrator expressed Issues with the residents pendant calls have also been corrected and staff are alerted when a resident requires assistance and push their call button as the phones are working properly. Based on the information received and records gathered, both allegations for, Facility's signal system is not working properly and Facility staff did not answer residents' calls in a timely manner are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Mar 11, 2024 · control 21-AS-20231206104607

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Mar 12, 2024

1569.269(a)(6)Enumerated rights; severability(a)Residents of residential care facilities for the elderly shall have all of the following rights: (6)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on Investigation and records reviewed, the licensee did not comply with the section cited above by not ensuring that residents call buttons were working properly and reaching staff when they required assistance. R1 waited about 32 minutes & then left their room to search for staff to provide them with needed medication. This is an immediate risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2024

Plan of correction: Facility to send in written statement on action taken and how facility will stay in compliance. POC due date for written statement due 3/14/2024. Facility to provide in-service training to staff regarding regulation and reporting when there is an issue with the call system. Proof of training due 3/21/2024 attention LPA A Canela

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Apr 5, 2024

87303(i)(1)(B)Maintenance and Operation (i)Facilities shall have signal systems which shall meet the following criteria: (1)All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidenced by: Based on statements received, it was corroborated that there was an issue with the phones not working properly and staff were not properly alerted when they needed to open the front door after hours and pendant calls were not always transmitting a signal to staff. This is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2024

Plan of correction: Facility purchased and installed a new phone system. Facility to submit a written plan on how it is being used and how facility will stay in compliance. Facility to conduct in-service training and provide plan on how the call system, pendant calls will be monitored to ensure they are working properly. Plan of Correction due 4/5/2024 attention LPA A Canela.

Type of visit: Required - 1 Year

LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Facility Chef Saverio Gratteri. Executive Director Susan Allen showed up and completed the visit. This facility is connected to three other buildings for a total of four buildings connected by walkways. The other three buildings are independent senior living communities not under the jurisdiction of Community Care Licensing Division (CCLD). The building that is licensed has three floors. Each apartment has a kitchenette and a full bathroom. LPA toured seven apartments and no concerns were found. There are common areas on each floor. During today's visit LPA observed the following which is not a safety concern to the residents: -one wing which has four apartments is sealed off because the building had a plumbing issue and in order to reach the pipes the floors in that area had to be taken out. The resident affected were relocated to empty apartments and the wing is sealed off for safety reasons. LPA was informed the construction is almost complete. The following shall be updated and submitted to CCLD by 02/10/2024: -LIC 500 facility personnel or staff schedule -LIC 308 designation of administrative responsibility -paperwork appointing current executive director -liability insurance LPA obtained updated contact information. Multiple topics were discussed No deficiencies cited.the state’s words, verbatim · CDSS document, Jan 13, 2024

Allegation investigated: Uncleared adult has access to residents in care

Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of opening a complaint investigation, regarding the above listed allegation. LPA met with Executive Director, Susan Allen, toured all three floors of assisted living facility, made observations and took statements. It was alleged there is an uncleared adult who has access to residents in care. Investigation revealed staff S1 went through the required fingerprint process and associated to this facility, but S1's clearance was not granted by the department and S1 was placed under pending status; meaning that S1 was not cleared to work or be in this facility until proper clearance was granted. The facility allowed S1 to be in the facilities assisted living area by hiring S1 as an outside contractor when clearance was in pending status. Continue report see LIC9099-C Substantiated Continue report from LIC9099 Interviews conducted revealed S1 had access and was in the licensed part of this facility providing the same work as other facility maintenance staff. A $100.00 civil penalty was assessed on todays date for uncleared adult S1. Allegation, Uncleared adult has access to residents in care, is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Giventhe state’s words, verbatim · CDSS document, Jan 4, 2024 · control 21-AS-20231229150011

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 5, 2024

87355(e)(1)Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to Health & Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met, As evidenced by: Complaint investigation revealed staff S1 did not have the proper fingerprint clearance & had access to residents in care. This is an immediate risk to the Health & safety of residents in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: Facility to submit a written plan that they understand regulation and how it will maintain compliance. Facility also informed LPA S1 would not be in the facility until S1 received the proper clearance or received a criminal exemption. Written plan POC due 1/5/2024 A civil penalty of $100.00 was applied for uncleared adult.