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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700471
Report Date: 07/24/2024
Date Signed: 07/24/2024 12:49:45 PM


Document Has Been Signed on 07/24/2024 12:49 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: 76DATE:
07/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH: Executive Director- Ricky DavidTIME COMPLETED:
01:30 PM
NARRATIVE
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On 7/24/24 Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a Case Management visit. LPA met with Executive Director (ED) Ricky David and explained the purpose of the visit.  

On 03/28/24 LPAs conducted a medication audit during a complaint investigation. During the investigation, the following deficiencies were found:  

LPAs observed that R1 medication Amlodipine Besylate 5 MG had a start date of 03/09/24 had two (2) extra tablets than what was documented as dispensed. The MAR indicated that R1 had not missed or refused the medication. R1s medication for Metoprolol Succinate 25 MG with a start date of 03/14/24 had one (1) extra tablet than what was documented as dispensed. The MAR indicated that R1 had not missed or refused the medication.   
 
Medication audit revealed several staff are pre-pouring resident's medications for up to 24 hours. Additionally, it was learned staff are keeping their pre-poured medications locked in a cabinet that only that specific staff has access to.
  
Violations were observed during the Department medication audit therefore citations will be issued and listed on the LIC809-D.

Exit interview and appeal rights provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/24/2024 12:49 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: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited
CCR
87465(a)(4)

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87465Incidental Medical and Dental Care.(a)A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
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Licensee is to conduct a training with staff on MAR and how to correctly document.
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This requirement is not met as evidenced by:
Based on observation and interview medications were not being documented accurately.This poses a potential health and safety risk to residents in care. 
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Type B
07/31/2024
Section Cited
CCR87465(h)(5)

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87465 Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container.  No medications shall be transferred between containers.  .
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Licensee agrees to cease pre-pouring medications immediately. Licensee shall schedule an in-service training and submit names of those attended.
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This requirement is not met as evidenced by:
Based on observation and interview, medications are being pre-poured more than 24 hours in advance. LPA interviews indicated that medication is pre-poured for four (4) days in advance. This poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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