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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700471
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:52:48 PM


Document Has Been Signed on 01/30/2024 12:52 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 75DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator- Ricky David JRTIME COMPLETED:
01:00 PM
NARRATIVE
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On 01/30/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection. LPA met with Executive Director (ED),Ricky David JR, and explained the purpose of the visit.

LPA and ED conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: ten (10) resident rooms, three (3) laundry rooms, kitchen, dining room, library, theater, mail area, medication room and common areas. LPA observed residents in common areas participating in activities and in the dining room having lunch. The residence was found to be clean, safe, sanitary and in good condition.

LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents.

LPA conducted a file review of eight (8) resident files and eight (8) staff files. Resident files had all the required documents present in files. Staff files are missing First Aid training. ED stated they are having First Aid training on 02/28/2024.

LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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Document Has Been Signed on 01/30/2024 12:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87411(c)(1)
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 8 out of 8 staff does not have first aid training which poses a potential health and safety risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Licensee will submit to LPA Ratajczak a statement of understanding that all stuff must have First Aid training by POC due date. Licensee has a planned First Aid training scheduled for staff on 02/28/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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