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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700471
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:16:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20231010105714
FACILITY NAME:COGIR OF STOCK RANCHFACILITY NUMBER:
342700471
ADMINISTRATOR:DAVID JR., RICKYFACILITY TYPE:
740
ADDRESS:7418 STOCK RANCH RDTELEPHONE:
(916) 725-7418
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:99CENSUS: 97DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director: Ricky DavidTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not providing adequate food service to residents.
INVESTIGATION FINDINGS:
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On 11/30/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 10/10/2023. LPA met with Executive Director (ED), Ricky David, and explained the purpose of the visit. During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complaint investigation.According to the interview statement received, the facility’s kitchen was in disrepair. Due to the kitchen being in disrepair staff were not providing adequate food service to residents in care. The Department received interview statements from a total of four (4) facility staff. All four staff indicated staff provided adequate food services to residents in care. Staff were able to provide food to residents promptly. The kitchen was flooded with soap water after dinner was over and meals were served to residents in care. Due to the information above, CCL finds the allegation to be UNSUBSTANTIATED, meaning 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.
An exit interview was conducted, and a copy of the report was left at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20231010105714

FACILITY NAME:COGIR OF STOCK RANCHFACILITY NUMBER:
342700471
ADMINISTRATOR:DAVID JR., RICKYFACILITY TYPE:
740
ADDRESS:7418 STOCK RANCH RDTELEPHONE:
(916) 725-7418
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:99CENSUS: 97DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director: Ricky DavidTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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- Licensee is not ensuring facility kitchen is kept clean .
- Licensee is not addressing sewage problem at facility.
- Licensee does not ensure the facility has working toilets.
INVESTIGATION FINDINGS:
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On 11/30/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 10/10/2023. LPA met with Executive Director (ED), Ricky David, and explained the purpose of the visit.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, admission agreement, preplacement appraisal, and appraisal/needs and services plan.

Continue on page LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20231010105714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COGIR OF STOCK RANCH
FACILITY NUMBER: 342700471
VISIT DATE: 11/30/2023
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Allegation: Licensee is not ensuring facility kitchen is kept clean. – Unfounded.

The Department received an interview statement from the complainant indicating that the facility’s kitchen was in disrepair. ED and upper management asked kitchen staff to produce food in an unsafe environment. The Department conducted interviews and received statements from a total of four (4) facility staff. It was discovered the kitchen was in disrepair on 10/09/2023 at approximately 8:30 PM. Interview statement received from staff (S1) indicated that kitchen staff was done prepping/cooking the food for residents in care before the kitchen was in disrepair. Interview statement received from S2 indicated, staff would clean kitchen twice a day from 2 PM and 7 PM. The floors are mopped and swept once a day. Interview statement received from S3 indicated kitchen was not dirty while staff were prepping and cooking food for residents in care. Everything was clean except the floor. There was soap water on the floor. The kitchen was flooding with water after dinner around 8 PM. Interview statement received from ED indicated that it was not a sewage issue. There was clear water coming from the dishwasher machine. ED notified Regional Vice President Operation the same day at approximately 8:30-9:00 PM. Regional Vice President Operation was present at the facility after being notified to help clean the kitchen and hired Blue Team to sanitize the kitchen.

The Department requested a repair invoice for review. According to Blue Team Daily Field Report, the first responder cleaned and sanitized affected kitchen flooring on 10/10/2023. Blue Team inspected nearby walls and found no moisture.

Allegation: Licensee is not addressing sewage problem at facility. – Unfounded.

The Department conducted interviews and received statements from a total of four (4) facility staff. It was discovered that the facility’s kitchen was in disrepair on 10/09/2023. Interview statement received from ED indicated that it was not a sewage issue. There was clear water coming from the dishwasher machine. ED notified Regional Vice President Operation the same day at approximately 8:30-9:00 PM. Regional Vice President Operation was present at the facility after being notified to help clean the kitchen and hired Blue Team to sanitize the kitchen.

The Department requested a building permit and repair invoice for review. The building permit indicated the facility was being billed for plumbing permit. According to Blue Team Daily Field Report, the first responder cleaned and sanitized affected kitchen flooring on 10/10/2023. Blue Team inspected nearby walls and found no moisture.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20231010105714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COGIR OF STOCK RANCH
FACILITY NUMBER: 342700471
VISIT DATE: 11/30/2023
NARRATIVE
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The Department received the Heating and Air Design Corporation invoice for review. The Heating and Air Design Corporation have furnished the material and performed the labor necessary for the completion of:

1. Removal/replacement of a 4 “main kitchen drain line approximately 93 feet long to the main 6” in the hallway by bursting method.

2. Concrete-saw and dug two (2) additional connections in the kitchen for new connections for the employee’s bathroom and walk-in floor drain.

3. Floors drain behind steamer will be abandoned due to connection is under the walk-in freezer box. This line will be attached to far wall with ¾” copper tubing to drain to ice machine floor drain.

4. Library will need to be tented and the concrete floor saw cut 3’x5’ to access common area bathroom tie-ins.

5. Approximately 30’ of hallway will need to be tented and evacuation plans rerouted around the front area.

6. First priority is to dig down in all areas to affected pipe areas and attachments.

7. Put in shoring safety in for every 4’ and deeper.

8. Realign entire branch line by the bursting method/ensure grease trap has been drained.

9. First attach branch line to hallway line to continue flow and work backwards connecting common bathrooms, floor drain for walk-in freezer, employee bathroom, and outside grease trap line.

10. Leave open for a day to check for any leaks.

11. Start backfilling from kitchen to main hallway drain. Compact fill and have a concrete truck pump concrete back and contractor do smooth finish.

12. Remove all tenting after two (2) days of curing. Have a team come and clean all affected areas.

The Department requested Citrus Heights Police Department, Code Enforcement Officer, to conduct a joint visit to the facility with LPA Keosavang on 10/19/2023. The Code Enforcement Officer received a work order from the facility and the case has been closed. The Department received interview statement from Blue Team inspector. Inspector stated the repairs took 13 days.

It was discovered that the facility did their due diligence and addressed the issue by hiring outside vendors for repairs in a timely manner.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20231010105714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COGIR OF STOCK RANCH
FACILITY NUMBER: 342700471
VISIT DATE: 11/30/2023
NARRATIVE
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Allegation: Licensee does not ensure the facility has working toilets. – Unfounded.

The Department conducted interviews and received statements from a total of four (4) facility staff. Interview statements received from all four staff indicated the bathroom in the staff break room is currently out of order. All four staff indicated there are other bathrooms in the facility that are available for staff to use. Interview statement received from ED indicated that all residents in care have a bathroom in their rooms. The only toilets that weren’t working were the toilets in the staff’s break room. No residents’ toilets were jeopardized. ED state staff can use any other bathroom. The facility has a couple of vacant rooms with bathrooms that staff can use.

The Department received interview statement from Blue Team inspector. Inspector indicated toilet in staff's break room were out of service along with one common area bathrooms. The facility opened bathrooms down the hall from the common area bathroom. The toilets in the break room and common area was repaired in 7 days.

Based on records reviewed, facility observations and interviews, all the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.



Exit Interview conducted. A copy of this report has been provided to the facility. No citations have been issued during today's visit.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5