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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700471
Report Date: 05/15/2024
Date Signed: 05/15/2024 01:18:05 PM

Document Has Been Signed on 05/15/2024 01:18 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/
DIRECTOR:		DAVID JR., RICKYFACILITY TYPE:
740
ADDRESS:7418 STOCK RANCH RDTELEPHONE:
(916) 725-7418
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 99TOTAL ENROLLED CHILDREN: 0CENSUS: 75DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Executive Director- Ricky DavidTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 05/15/2024, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 05/3/2024. LPA met with Executive Director (ED), Ricky David and explained the purpose of the visit.

The incident occurred on 05/01/2024 at approximately 5 PM facility staff observed R1 to be missing when a med tech went to R1s room to give R1 their PM medication. Facility staff conducted a search throughout the facility and it was noted that R1 was no longer in the facility. Resident was located later that night in Elko Nevada. Based on R1's LIC602 Physician's Report, signed on 10/24/2023, indicated that R1 was deemed unable to leave the facility unassisted.

LPA and ED discussed ensuring that staff are aware which residents are able to leave the facility unassisted. ED informed LPA that R1 does not have a dementia diagnosis but a fall risk. LPA clarified that if the LIC602 indicates resident cannot leave unassisted then the facility is to comply. Additionally, LPA and ED discussed that R1 had recently moved from independent living to assisted living and that R1 did not want to live at the facility any longer. R1 is currently not living at the facility.

As a result of the incident, deficiencies cited. Please see LIC 809-D, per Title 22 Regulations.

Exit interview conducted, a copy of the report and appeal rights left at the facility.
Laura MunozTELEPHONE: (916) 263-4743
Cheyenne RatajczakTELEPHONE: (916) 969-7879
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 01:18 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/16/2024
Section Cited
HSC
1569.312

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1569.312 Every facility required to be licensed under this chapter shall provide at least the following basic services:
(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community.
This requirement is not met as evidenced by:
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Licensee is to submit a plan of how facility will ensure that staff know the general whereabouts of residents and plan a staff training of the plan.

POC to be emailed to LPA by POC due date.
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Based on file review and interview, the Licensee did not comply in the section cited above as R1 was observed to have left the community and is unable to leave the community unassisted which poses an immediate health and safety risk for 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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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