342700471-12-27-2023-59-AS-LMUZ-CZ7PNX-20240105102837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700471
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:10:44 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
07/21/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230721111141

FACILITY NAME:	COGIR OF STOCK RANCH		FACILITY NUMBER:	342700471
ADMINISTRATOR:	DAVID JR., RICKY		FACILITY TYPE:	740
ADDRESS:	7418 STOCK RANCH RD		TELEPHONE:	(916) 725-7418
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	99	CENSUS: 100	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Business Office Manager: Jenette Mariano		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Questionable death due to neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Sarena Keosavang and Cheyenne Ratajczak arrived at the facility unannounced 12/27/2023 to deliver findings for a complaint Community Care Licensing (CCL) received on 07/21/2023. LPA met with Business Office Manager, Jennette Mariano, and explained the purpose of the visit.

The Department requested pertinent documents relevant to the complaint investigation such as, resident (R1) physician's report, identification and emergency information, death report, eMAR, admission agreement, assessments, medical records, Metro Fire PCR, Devilbiss 5-litre Oxygen Concentrator instruction guide, policy and procedures to oxygen use for residents, policy and procedures for use of pulse oximeter, staff training or in-service records, SOC 341, staff roster and schedule, and Apria records.

Continue on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230721111141

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: 12/27/2023

NARRATIVE

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On 07/19/2023, Emergency Medical Services (EMS) Personnel were dispatched to Cogir of Stock for a resident (R1) with shortness of breath. Upon arrival at the facility EMS personnel observed that R1’s oxygen concentrator was turned off. Two (2) EMS personnel reported that they heard staff (S1) state the machine had been turned off the prior night because it was beeping. S1 was asked about a back-up oxygen tank and nasal cannula was not in place. S1 stated they had called for a new machine and were told one would be delivered the next day. S1 told EMS, “We didn’t know what else to do.”

The Department interviewed and received statements from a total of eleven (11) facility staff and two (2) residents. Interview statement received from S1 indicated that the concentrator was alarming on 07/18/2023, and S1 called Apria Health Care to request a new concentrator. S1 made inconsistent statements about when S1 first noticed R1’s oxygen concentrator was turned off and cannula not in place, before calling 911. When S1 was first interviewed, S1 stated R1’s oxygen was off and nasal cannula was not in place when S1 first checked on R1. During a follow-up interview, S1 stated did not remember noticing R1’s nasal cannula and only recalled being aware of the concentrator being off during the second medication passing, when S1 discovered R1 having shortness of breath and calling 911. S1 denied telling EMS that the machine had been turned off and stated S1 had later assumed that the overnight shift must have turned the machine off. Multiple staff were interviewed, and all denied turning the machine off. Interview statement received from overnight staff (S2) admitted that the machine had been alarming and had quit working sometime early in the night, but that S2 had been able to reset the concentrator to get it working again.

Medical records obtained and witness statements provided that R1 had been previously diagnosed and treated for ST-Elevation Myocardial Infarction in June 2023. It was noted that R1 had a history of chronic respiratory failure. Medical personnel were interviewed and stated it would be difficult to determine if a lack of supplemental oxygen preceded or contributed to R1’s death. R1’s pronouncing physician was interviewed and stated R1’s respiratory failure could have happened for several reasons, regardless of R1 being on or off oxygen. Therefore, there is not sufficient evidence to substantiate the allegation of wrongful death.

Based on the Department’s investigation as stated above, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 report provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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