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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700471
Report Date: 10/08/2025
Date Signed: 10/08/2025 02:55:41 PM

Substantiated


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
04/18/2025 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20250418113410
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: 74DATE:
10/08/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Ricky DavidTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility failed to meet reporting requirements
INVESTIGATION FINDINGS:
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On 10/08/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 04/18/2025. LPA met with Executive Director (ED) Ricky David and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and record review.
Interview with ED revealed the facility could not locate the incident report for R1’s fall on 02/13/2025. CCL conducted a file review and it was revealed that an incident report was not submitted for R1’ fall on 02/13/2025. Based on file review and interviews, the facility did not ensure incident reports were created and sent to CCL as required. Therefore the preponderance of evidenced standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of the report and appeal rights left at the facility.  
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
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 4
Control Number 59-AS-20250418113410
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2025
Section Cited
CCR
87221(a)(1)(B)
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(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

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Licensee is to come up with a procedure for steps to follow regarding reporting requirements and what requires an incident report. Licensee will then train staff on the procedure by POC due date.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above in incident reports were missing or not created regarding R1’s fall which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/18/2025 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20250418113410

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: 74DATE:
10/08/2025
ANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Ricky DavidTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Questionable death
Resident sustained multiple falls resulting in serious bodily injury
INVESTIGATION FINDINGS:
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On 10/08/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 04/18/2025. LPA met with Executive Director (ED) Ricky David and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and record review.


Please contiune to LIC9009C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250418113410
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: 10/08/2025
NARRATIVE
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Allegation: Questionable death- Unsubstantiated 
A review of R1’s death certificate listed that they passed away in May 2025 due to a Traumatic Intracerebral Hemorrhage due to a ground level fall with a time interval between onset and death listed as months. On 02/13/2025, R1 sustained an unwitnessed fall and was sent to the hospital. Medical records show a “possible small left frontal Intracerebral Hemorrhage.” No fractures or other injuries were documented in the medical records. R1 was placed on hospice following this incident. Conflicting statements were provided on whether R1 sustained additional minor falls after 02/13/2025 and while being on hospice.  
 
Deputy Coroner (DC) stated that the multiple falls made the brain bleed “a little worse each time.” DC stated this is “common in older people though, especially with R1 being 100 years old.” DC was not concerned that R1 may have passed away due to neglect by the facility staff. DC stated there is “no way” of knowing which fall contributed to R1’s death. It is unclear if the major fall on 02/13/2025 was as a result of staff neglect. Prior to that, R1 had only sustained one fall at the facility on 05/20/2024 and did not require any specialized fall interventions or special checks.  
 
Allegation: Resident sustained multiple falls resulting in serious bodily injury- Unsubstantiated 
Records revealed that R1 resided at the facility for approximately two years and sustained two major falls during that time. The first fall occurred on 05/20/2024 and resulted in a skin tear. The second fall occurred on 02/13/2025 and resulted in a “possible small left frontal Intracerebral Hemorrhage.” No fractures or other injuries were documented in the medical records.  
 
Records and interviews support that R1 was not a fall risk and was primarily independent. R1 did not require specialized checks or specific fall measures. Conflicting statements were provided on whether R1 sustained additional minor falls while residing at the facility indicating need for specialized fall prevention interventions. R1 sustained an additional fall on 04/04/2025 while on hospice. Hospice care staff were notified and directed the facility staff to not send R1 to the hospital due to no injuries seen. 
Based on this information, these allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.  

Exit interview conducted. A copy of the report and appeal rights left at the facility.   
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4