Inspector’s narrative
What the inspector wrote
The Regional Vice President of Operations stated she has seen photos of the missing furniture in R1's room before and after the relocation but she stated that she did not have any specific details because it was handled by the previous management company, Integral Senior Living (ISL) and they did a major clean up before the residents returned.
According to R1, many furniture and other personal belongings were missing from the apartment after returning to the facility. R1 also stated that a laptop was missing, many garbage bags that were packed with personal items were thrown away without his/her permission.
According to R1's family member, they made a police report after discovering the furniture and other items were missing from R1's apartment and they have photos to proof. R1's family member stated that they have shared these photos with Cogir management, and they were told that they would be reimbursed when the police report was finalized.
Based on the before and after photos of R1's apartment, it revealed that many furniture was missing such as a bookshelf, table, chairs, entry furniture, etc.
Based on the written communication dated February 4, 2025, the Regional Vice President of Operations stated that the facility will reimburse R1's family member for the missing items when the police report was finalized. However, a copy of the police report dated 2/18/2025 was provided but the reimbursement was not issued.
After the investigation, this allegation is deemed to be substantiated because there was photos to proof that furniture and other items were missing from R1's apartment after R1's returned to the facility, and there was a written communication in February 2025 from the Regional Vice President stating that R1 will be reimbursed but as of today, R1 and R1's family member has yet been reimbursed.
Regarding the allegation of - illegal rate increase, the reporting party stated that the facility increased R1's rent and charged for the administrative work.
As part of the investigation, LPA interviewed R1, R1's family member, the State Official, the Director Of Health Services, the Administrator, the Business Office Director, and the Regional Vice President Of Operations.
According to R1, the facility increased the rate for level of care and it was based on an assessment but R1 did not remember having any type of assessments. In addition, R1 stated that R1's family member was forced to pay for the increase as R1's family member did not want the facility to evict R1 due to non-payment.
According to R1's family member, initially the facility stated that the level of care increased was a mistake as the billing was done by an outside company and it would be corrected. However, in February 2025, the facility informed them that there would be a level of care increase starting March 2025 due to extra care. R1's family member stated that R1 did not require any extra care, and they have never gotten a written notice of the level of care increase and an explanation of the increase.
LPA interviewed the Administrator and the Director Of Health Services, and neither could provide any details as they were both new to the facility.
LPA interviewed the Business Office Director who did not have any details pertaining to the level of care increase but stated that R1's family member has been paying the additional level of care increase since April 2025.
LPA interviewed the Regional Vice President of Operations who stated that the monthly rent was increase due to R1's behaviors.
LPA interviewed the State Official who stated that he/she was invited to a meeting in February 2025 with the Regional Vice President of Operations and R1's family member to discuss the level of care increase but during the meeting, there was no conversation about the care, it was about R1's behaviors that triggered the level of care.
Based on R1's care plan detail dated 12/30/2024, R1 was independent and did not require care. In addition, the care plan detail was not signed by the resident, the party responsible and facility representative to proof that it was reviewed and discussed accordingly.
After the investigation, this allegation is deemed to be substantiated as the facility increased R1's level of care but based on R1's care plan detail dated 12/30/2024, R1 did not have any care needs. In addition, R1 and R1's family member did not receive a written notice with details explaining the level of care increase.
Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.
Report was discussed with Administrator, and Appeal Rights provided.
Regarding the phone services, the Administrator and the Business Office Manager stated that the phone on the 3rd floor is always available for residents to use. They also stated that R1 utilized that phone as well as the phone in S3's office to make confidential calls.
According to R1, there is a phone of the 3rd floor, and he/she has been using that phone, but it is not always available. R1 also stated that he/she has been using the phone in S3's office to make confidential calls and R1 stated that he/she has a cell phone.
According to S3, R1 has been going to S3's office very often to use the phone and S3 would leave the office to private privacy. S3 reported that there were times when R1 spent a long time on the phone where S3 needed to tell R1 that she needed to do something in the office.
According to the State Official, the facility has been accommodating R1 with providing a phone services.
Regarding S1 staying in the lobby and talking to the receptionist and/or other staff after S1 clocked out for work, LPA interviewed S1, the Administrator, S2, and other residents.
According to S1, he/she stayed after work to decompress after a long day of work by talking to different people. S1 stated that he/she did not bother anyone by doing that.
According to the Administrator, the lobby area is not a private space to have any private conversation. The administrator stated lobby is a common space for everyone to use including S1, other staff members, visitors, residents, etc. The Administrator stated that when a resident wants to have a private conversation with a staff, it will be conducted at a private space.
LPA interviewed other residents and all of them reported that their privacy was honored by the facility.
Regarding hiring professional movers to assist with moving residents back to the facility due to the emergency evacuation except for R1, R1 stated that the other residents were provided with a company credit card to pay for the movers except for R1.
According to the State Official, R1 was very particular of the transportation arrangement and R1 arranged for a friend who has a van to drive R1 back to the facility. The State Official stated that some other residents moved their furniture to their temporary location but R1 did not, so the van was big enough to fit all of R1's belongings.
According to the Regional Vice President of Operations, the relocation arrangements were made by the previous management, ISL and she did not have the details.
After the investigation, this allegation is deemed to be unsubstantial.
Regarding the allegation of - facility provided false assessment to CCL to support the eviction, the reporting party stated that the facility provided false unusual incident reports concerning to R1 to CCL of the events that never happened.
As part of the investigation, LPA interviewed R1, the Administrator, and reviewed unusual incident reports.
According to R1, the facility reported false incidents to CCL, for example, he/ she was yelling and screaming, wearing inappropriate attire in the public area, and the facility provided accurate information to the mobile crisis team that resulted in R1 being hospitalized.
According to the Administrator, the facility was following the reporting requirement by reporting the incidents that were observed. The Administrator stated that there were a couple of events that triggered a call to a local community outreach support agency and R1 was taken to the hospital for further evaluation based on their assessment of the situation.
Based on the incident reports submitted by the facility, each of them indicated an unusual incident that happened at the facility which triggered the facility to report it to the Department as part of the Reporting Requirement under Title 22.
After the investigation, this allegation is deemed to be unsubstantiated.
Although the above investigations 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 allegation is UNSUBSTANTIATED.
Based on the eviction letter, it indicated the reasons supporting the eviction, and other required resources. In addition, a copy of the letter was provided to CCL.
After the investigation, this allegation is deemed to be unfounded as the facility provided proper notification to R1 and to the Department according to Title 22 Regulation- Eviction Procedures.
Based on interviews, record review, and observations, the department has determined that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED.
Report is reviewed and copy is provided.