502701180-6-24-2026-27-AS-NWPN-DVCV8L-20260624161255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701180
Report Date: 06/24/2026
Date Signed: 06/24/2026 04:18:04 PM

Document Has Been Signed on 06/24/2026 04:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	COGIR OF TURLOCK		FACILITY NUMBER:	502701180
ADMINISTRATOR/ DIRECTOR:	HERNANDEZ, JACKIE		FACILITY TYPE:	740
ADDRESS:	3791 CROWELL ROAD		TELEPHONE:	(209) 664-9500
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY: 100		CENSUS: 65	DATE:	06/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Jackie Hernandez		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE
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	Licensing Program Analyst, LPA, Noel Wolf Petersen and Licensing Program Manager, LPM Liza King arrived unannounced to conduct a annual inspection of the facility. The LPA and LPM met with the Executive Director Jackie Hernandez to explain the purpose of the visit. A physical inspection was completed, including but not limited to the bedrooms/bathrooms, the kitchen, the exterior and emergency route gate, the memory care unit, the common areas, and storage areas. Traffic areas are unobstructed and well lit. The fire extinguishers are dated may 6 2026, and the first aid kit has all necessary components. there are some ongoing repairs of the air conditioning, (a condenser tray leaking), the Maintenance director provided that the facility was probably going to replace the unit. at the time of the annual inspection, the air temperature within the facility is in range 68-85, and the LPA gave guidance that temperature should be maintained for the residents through the repair/replacement of the unit. Bedrooms * bathrooms: One of 6 observed bedrooms was malodorus for R1. LPA gave guidance that increased housekeeping checks should be included with the care plans for those residents with with inconteince issues. 5 of 5 resident rooms checked have functional bathroom hardware(sink facuets, showers, toilets). Water delivered at the sink measured between 110 and 115. 6 of 6 Bedrooms are furnished with required furniture, bathrooms have secure grab bars. Kitchen: Perishable/nonperishable food storage is at a capacity for 2/7 days for 65 residents plus 3 snacks per day, the sharps and toxics are stored seperately from each other and secure from the residents. Food for the residents is able to be held within the walk in, and a snack bar is maintained for resident access between meals. 4 residents have a concern about increasing menu options, specifically the availability of vegetables. The facility had a recent resident council and a meal suggestion survey where the issue was raised, and the LPA gave guidance that grievance procedure process should play out from here. Continued on c page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COGIR OF TURLOCK	FACILITY NUMBER: 502701180
	VISIT DATE: 06/24/2026

NARRATIVE

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1 meal service was observed, turkey, mashed potatoes, gravy, cranberries, a jello/icecream. Senior Kitchen staff in interview outlined a desire to be more responsive to resident menu requests by adding additional vendors, adding a deep fryer, and adding a salad bar. There was a recent issue, a lack of spoons which was impacting service to the residents. New spoons have been ordered.

1 med pass was observed. Medtechs were observed to be handing out medications to the approprite parties in a timely fashion. No concerns with the medpass as observed. Recent medication MARs were checked for 11 residents, 1 had a discrepancy resolved as part of a complaint earlier in the month, and the other 10 were error free. There is a outstanding discrepancy on a the controlled substances log, which the facility resolved internally to the satisfaction of the department at this time.

Exterior is clean, there is a water feature back by memory care the LPA gave guidance should have rocks added to make the basins shallow enough as to mitgate any risk of drowning. Evacuation routes all exit out the front of the facility which is ungated. Memory care doors unlock in the event of a fire.

LPM reviewed 10 client files. Resident files were reviewed for the health training, admission agreements, recent medical assessments, and recent significant events. One resident deteriorated rapidly after a fall, internal investigation?

LPM reviewed 10 staff files. 2/10 staff did not have current first aide training. A discussion occurred with the Administrator who verified that training is scheduled to be completed by 06/26/2026. 3/10 staff files reviewed showed there were past due annual trainings to be completed. According to the Administrator these staff have been counseled and will have the trainings completed by 06/26/2026. It appears that the facility needs to put systems in place to better hold staff accountable for upcoming and past due trainings. The facility currently uses relias which runs reports to show trainings that are coming/due and past due. Guidance was provided as well that although some trainings are only required upon initial hire, there are subjects which would be a best practice to revisit on occassion. Additionally, the facilities current practice is to use resumes in place of an application which provides a work history and is an acceptable alternative.

Continued on c page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COGIR OF TURLOCK	FACILITY NUMBER: 502701180
	VISIT DATE: 06/24/2026

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Common areas: Common areas were observed to have adequate space for activites. in interview with the activities director and assistant activities director, they make observations about the accesibility and preferance of the clients for the scheduled activities. todays activities are morning walk, carnival, yoga, bingo, and card game(corner kings). the memory care has mostly the same activites minus the carnival.

Memory care: is clean, traffic areas are well lit, 4 of 4 bedrooms have required furnishing and furniture, 4 of 4 bathrooms have functional hardware. water temperature delivered at the sink are measured between 108 and 112.

Administrator files were reviewed including the administrators certificate, facility license, required postings (ombudaman poster, client rights poster, federal workers rights poster, activity calenders, menu calender), Liability insurance, workers comp insurance.

No citations issued as part of this visit, a copy of the report was read and given to the administrator. Exit interview conducted. The Annual needs futher investigation to review service notes, emergency plan, fire drill log, pull cord log, resident council meeting notes, and infection control plan.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

LIC809 (FAS) - (06/04)

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