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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700471
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:28:49 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
09/26/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230926154214
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: 99DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director: Ricky DavidTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not assist residents with showering.
INVESTIGATION FINDINGS:
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On 11/02/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 9/26/2023. LPA met with Executive Director, Ricky David, and explained the purpose of the visit. The Department interviewed facility staff and obtained pertinent documents such as, resident’s (R1) physician’s report and service plan. According to R1's phsycian's report, R1 is unable to bathe self. According to R1's service plan, R1 requires hands on assistance from one staff two times weekly. Interview statement received from staff indicated, staff were unable to assist R1 with showers on scheduled day. Staff indicated facility was experiencing staffing shortages. Interview statement received from ED indicated there were two showers scheduled for Saturday, 9/23/23. There were two caregivers and one Med Tech scheduled for that shift. Shower was rescheduled for another day due to staff call out. Interview statement received from R1 indicated, R1 did not receive assistance with showers on scheduled days. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D. Appeal rights provided. Exit Interview conducted and report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 3
Control Number 59-AS-20230926154214
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: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/09/2023
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescibed
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Facility to submit in written plan of understanding regulation section 87464 by POC due date 11/09/2023.
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 medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on interviews and records review, staff did not assist R1 with scheduled shower which poses a potential health and safety risk to resident 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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
09/26/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230926154214

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: 99DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director: Ricky DavidTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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3
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9
Staff do not meet residents' dietary needs.
INVESTIGATION FINDINGS:
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On 11/02/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding. LPA met with Executive Director, Ricky David, and explained the purpose of the visit. The Department interviewed staff and obtained pertinent documents such as, resident’s (R1) physician’s report, service plan, food menu, and physician's diet order. Physician's diet order indicates, R1 is on NAS (no added salt) diet. Interview statement received from R1 indicated, the facility does not provide sugar free foods for diabetics. The Department interviewed a total of 4 staff and 4 residents. Staff indicated there are a variety of food options residents can choose from. There is a salad bar, all day menu, specials, and sugar free desserts. Fruits and vegatables are available at all times. The kitchen chef was interviewed and stated they follow a weekly menu that is based on the needs listed in the dietary roster. LPA toured facility and viewed the meal and dining area at lunch time. The Department has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation to be UNSUBSTANTIATED. Exit interview was conducted with Administrator and a copy of this report was provided to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 3