Cogir of Stock Ranch

Allegation investigated: Staff are not following universal precautions to prevent the spread of scabies

On 3/2/26, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with ED Jose Barajas. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on observation, record review, and statement reviewed, the facility was following infection control requirements. As a precaution, during the first sign of a rash, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged residents to stay in their room during the episode. It was observed facility had required PPE outside the resident room; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Unfoundedthe state’s words, verbatim · CDSS document, Mar 2, 2026 · control 59-AS-20251202083904

Allegation investigated: Staff are mismanaging resident's medication Staff did not respond to resident's calls for assistance

On 3/2/26, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with ED Jose Barajas. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Staff are mismanaging resident's medication Based on documents obtained and statements reviewed for September and October of 2025, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Eight staff interviews (8) indicated that staff were not aware of any medication errors. Four resident interviews (4) expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Staff did not respond to resident's calls for assistance During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on call logs and interviews, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that residents are waiting for assistance longer. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 59-AS-20251208103505

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on an incident report submitted to the Department on February 4, 2026. LPA met with Alyssa Kayl, Resident Care Coordinator, and Robert DeVol, Health and Wellness Director (HWD) stating the reason for today's inspection. LPA later met with Jose Barajas, Administrator Designee. LPA discussed the incident more in detail when staff went to get (R1) from their room and bring them to the dining room for lunch, and (R1) had started choking while eating." Care staff began the Heimlich maneuver, and then (R1) turned blue, lost consciousness and no pulse was detected. (S1) then began CPR and (R1) began breathing, and was taken to the emergency room for further medical evaluation. The facility was advised by the family that (R1) had been diagnosed with an upper respiratory infection and was doing much better the following morning, January 31, 2026, after being administered antibiotics. (R1) returned to the community on February 2, 2026 with no new medications or diet changes. The HWD stated the family instructed the facility to cut (R1's) food in small bites, with sips of liquid in between each bite. LPA reviewed and obtained copies of paperwork related to resident (R1). The Physician's Report (5/3/2025) does not indicate (R1) had any special diet prior to the incident. Since (R1) returned form the hospital, staff have been trying to encourage and bring (R1) to the dining room for all meals so they can have more supervision/eyes on them. (R1) has been adjusting fairly well to this new routine and has recovered fully from this incident. It appears the facility took appropriate steps in responding timely to (R1's) choking. There are no deficiencies issued in this report. Exit interview. Copy of report provided to Administrator Designee.the state’s words, verbatim · CDSS document, Feb 5, 2026

Type of visit: Required - 1 Year

On 01/15/2026 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 facility. Areas toured included but not limited to: ten (10) resident rooms, kitchen, dining room, library, theater, mail area, medication room and common areas. There are special provisions made for individuals with special dietary needs. The residence was found to be clean, safe, sanitary and in good repair. 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 compared medications to those being given for five (5) residents and found no discrepancies. LPA reviewed ten (10) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. LPA reviewed ten (10) staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. LPA completed the full care tool and no deficiencies was observed. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jan 15, 2026

Allegation investigated: Staff are mismanaging residents' medication

On 12/29/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 04/14/2025. 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 continue to LIC9099C... Substantiated Allegation: Staff are mismanaging residents' medication-Substantiated On 05/01/2025 LPA Ratajczak and LPM Munoz conducted a medication audit for five (5) residents. During the medication audit, the following was found: Resident #5 (R5) Discontinued order for Baclofen on 04/25/25. LPM and LPA observed medication to still be in the medication cart. Resident #6 (R6) Discontinued order for Aspirin on 04/29/25; for Breztru inhaler on 04/29/25 and for PreserVision AREDS on 04/15/2025. It was observed that all discontinued medications were in the medication cart. R6 had an order for Norco on 03/16/2025, the medication was not ordered and not in facility. Resident #7 (R7) Discontinued order for Midodrine on 04/24/25. LPM and LPA observed medication to still be in the medication cart. Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted a copy of the report provided and appeal rights provided. Allegation: Staff do not ensure residents' showering needs are being met- Unfounded Interviews revealed that residents receive their showers as scheduled. Sometimes showers are moved around but the shower is usually pushed back to the next shift. If a resident is not feeling well, they will ask staff to come back at a later time or to be moved to another day. Resident interviews revealed that some have hospice come in and give them showers also. Allegation: Staff do not ensure residents’ incontinence needs are being met-Unfounded Interviews revealed that staff check on residents every one to two hours for incontinence care needs. Depending on residents care needs, they may be checked more than every two hours. Residents will also push their pendants if they need any assistances between checks and staff respond. Allegation: Staff are not repositioning resident as needed- Unfounded The department conducted interviews with residents and staff regarding this allegation. Interviews with staff revealed that they reposition residents every two hours unless care plans specify otherwise. Resident interviews revealed that they have staff that come in and reposition them throughout the day. Allegation: Staff did not prevent resident from developing a pressure injury-Unfounded Interviews with residents revealed they currently do not have any pressure injuries or if they do they are being treated by hospice. Staff interviews revealed that those who do have a pressure injury they are already being treated by hospice. Allegation: Staff do not ensure residents' hygiene needs are being met-Unfounded Interviews with staff revealed that a resident’s care needs are documented on their care plan. Staff assist resident’s with hygiene needs based on a resident’s care plan and the resident’s preference. Allegation: Staff do not ensure that resident has clean bedding- Unfounded Interviews revealed that housekeeping will clean the bedding on the day the resident’s room is cleaned. In between that time care staff will observe to see if the sheets need to be changed in-between. If bedding needs to be changed, caregivers will change the bedding. Allegation: Staff do ensure resident rooms are clean and sanitary-Unfounded Housekeeping cleans the resident’s rooms once a week. In between that time if some additional cleaning is needed caregivers will assist. LPA observed nine (9) residents bedrooms. All rooms were observed to be clean and sanitary. Some residents do have animals. Those animals are the residents responsibility and to clean up after them if they are to go in their rooms. Residents who can no longer care for their animals families will hire outside help to come in and care for the animal. Interviews revealed that staff will clean up the animal feces if they see it when they are in the rooms. Based on information obtained through interviews, the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 59-AS-20250414151432

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 12, 2026

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. ...(4) The licensee shall assist residents with self-administered medications as needed. This poses a potential risk to health and safety for residents in care. This requirement is not met as evidenced by: Based on medication audit, facility is retaining residents discontinued medication and ordered medications are not in the facility.the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: Licensee is to conduct a medication audit and submit findings to the Department. Additionally, licensee will come up with a plan on how the facility will ensure all discontinued medications discarded timely as well as submit a training plan on how staff are trained to discard and document discontinued medications.

Allegation investigated: Facility failed to meet reporting requirements

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 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.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 59-AS-20250418113410

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87221(a)(1)(B) · Plan of correction due date: Oct 22, 2025

(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. 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.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

On February 11, 2025 at approximately 10:15 AM, Licensing Program Analysts (LPA), Farhaan Sarangi and Kayla Adkison met arrived unannounced at Cogir of Stock Ranch for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Administrator, Ricky David Jr. and was granted access into the facility. LPAs and Administrator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. LPAs observed a chair lift that is utilized in event of emergencies in the 3rd floor stairwell. LPA observed 1 out of 2 elevator permits not being displayed in the elevators (See LIC 9102-Technical Violation). Fire Extinguishers were found to be last charged on March 2024 at the time of the inspection. All smoke detectors sound directly to the fire station. Water temperature in facility bathroom is within Title 22 Regulation. LPA observed sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of vacant and occupied bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. First Aid kit was inspected and found to be appropriate during the inspection. Emergency Disaster Drill was last conducted in July 2024. (Report continued on LIC 809C) LPA reviewed 5 of 5 resident files and found those to be appropriate. LPAs reviewed 5 of 5 resident medication orders. However, during that review, LPA observed that 1 out of 5 residents had a discrepancy in the medication orders. LPA educated the Administrator on the importance of ensuring that documentation is up to date (See LIC 9102-Technical Violation). Administrator reported that he will follow-up with the Primary Care Physician and the Pharmacy. LPA reviewed staff files and found those files to be appropriate during the review. LPA requested the following documents to be sent: LIC 500- Personnel Report LIC 308- Designation of Facility Responsibility LIC 309- Administrative Organization Most up-to-date Liability insurance Emergency Disaster Plan Control of Property Register of residents Most updated Infection Control Plan Most recent Fire Inspection Report No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Feb 11, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility did not update Needs and Services Plans for residents

On 09/26/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to deliver findings regarding a complaint the Department received on 08/14/24. 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 obtained pertinent documents relevant to the complaint investigation. Please continue to LIC9099C… Unfounded Allegation: Facility did not update Needs and Services Plans for residents.- Unfounded The Department reviewed records and conducted interviews to investigate the allegation that the facility did not update Needs and Services Plans for residents. During the course of the investigation, LPA reviewed the needs and service plans for seven (7) residents who were said to be due for a reassessment during the month of August based off the system that the facility uses. Every six (6) months the system notifies staff that a reassessment is needed. It also notifies staff at the fourteen (14) day mark for a new resident in case changes need to be made to the assessment. Six (6) of the residents were due for a reassessment due to the fact it has been six (6) months since their last one. One (1) resident was due for a reassessment because they had just moved into the facility and was at their fourteen (14) day mark. During LPAs visit on 08/20/24 Staff #1 (S1) was in the middle of updating the seven (7) residents needs and service plan. S1 explained to LPA that at the beginning of the month they print out all needs and service plans that are due and post in caregiver office. Doing this allows all caregivers to give their input on each resident and make note of things that have changed. Based on information obtained through interviews, the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 59-AS-20240814132116

Allegation investigated: Staff did not give resident medication as prescribed. Staff illegally evicted resident

On 07/24/24, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to deliver final findings to a complaint the Department received on 03/12/24. LPA met with Executive Director (ED) Ricky David and explained the purpose of the visit. During the course of this investigation, the Department conducted interviews, record review and medication review for four (4) residents. Please continue to LIC 9099-C…. Unsubstantiated Allegation: Staff did not give resident medication as prescribed: On 03/28/24 LPA Ratajczak and LPA Mirlohi conducted a medication audit for four (4) residents. LPAs compared each residents Medication Administration Record (MAR) with medications centrally stored for the resident. MARs indicated that medications were administered and logged correctly and were given to residents per their doctor's orders. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff illegally evicted resident LPA conducted interviews and a record review of R1s file. It was suggested by the Health and Wellness Director that R1 gets reevaluated, because R1 was no longer at their baseline. Additionally, the Health and Wellness Director recommended that R1 have a one-on-one. ED was not present during the incident but was aware of what was taking place. ED was planning to put in a referral with their sister community Cogir of Folsom for R1. When the facility notices a change in a resident, the facility will get the resident reevaluated. If it is noted that a higher level of care is needed, the facility will put in a referral to move the resident to their sister community, Cogir of Folsom. During the course of this investigation the department interviewed multiple individuals and was provided with conflicting information regarding if R1 was given a verbal eviction. LPA cannot prove or disprove if a verbal eviction was issued based on the different version of events. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted a copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 24, 2024 · control 59-AS-20240312162027

Allegation investigated: Staff are not meeting residents showering needs Staff are not meeting residents needs

On 07/24/23, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 03/28/24. LPA met with Executive Director (ED) Ricky David and explained the purpose of the visit. During the course of this investigation, the Department conducted interviews and records review. Please continue to LIC 9099-C…. Unsubstantiated Allegation: Staff are not meeting residents showering needs LPA conducted interviews with four (4) staff and eight (8) residents. Resident interviews revealed that some resident’s showers do get missed while other residents stated that their showers do not get missed. One resident stated that sometimes their shower will get missed but if that happens, they will just take a shower by themself. One resident was offered to be switched to evenings to prevent missed morning showers. Interviews with caregivers revealed that three (3) caregivers work per shift. They are referred to as clusters. Cluster 1 and Cluster 2 are responsible for the overall needs of residents throughout that shift. Cluster 3 is responsible for showers and laundry for a handful of residents. Interviews further revealed that when someone calls out for their shift, especially the person who is cluster 3, it can be hard to make sure residents get the showers since caregivers now have to figure out who is going to assist with showers. Showers are set to be 30 minutes for each resident. Staff stated that occasionally showers take longer depending on the extent and then having to assist the resident in getting dressed. When this happens, it can set the caregiver back on showers. If AM shift misses a shower, they ask PM if they can fit it in. If not, they will ask residents if they can shower the next day. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff are not meeting residents needs Staff interviews indicated that they are not neglecting residents, but it can take them a while to respond to a page. Additionally, staff stated that sometimes the pagers do not work, or they are off on their timing. Staff stated that many residents will not push their call button because they know it can take a while. Resident interviews revealed that they feel like all their other needs are being met. One resident stated they understand that there are more residents than staff and that they just try to be mindful that staff may be with another resident. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted a copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 24, 2024 · control 59-AS-20240328105643

Allegation investigated: Staff did not meet resident’s dietary needs Staff did not comply with resident’s admission agreement Staff did not treat residents with dignity and respect

On 07/24/24, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to deliver findings regarding a complaint the Department received on 04/15/24. 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 obtained pertinent documents relevant to the complaint investigation. Interview with ED revealed that Resident #1 (R1) does not live on the assisted living floors of the facility but on the independent living floor which is not licensed by Community Care Licensing (CCL). Interviews further revealed that the facility did have a meeting with R1 and stated that during the meeting the issues were resolved.LPA interviewed R1 during the interview it was revealed R1 is independent and does not need care and supervision. The department has investigated the complaint alleging resident dietary needs are not being met, staff did not comply with admission agreement and staff did not treat residents with dignity and respect. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility. Unfoundedthe state’s words, verbatim · CDSS document, Jul 24, 2024 · control 59-AS-20240415163244

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Jul 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 31, 2024

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. 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.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Licensee is to conduct a training with staff on MAR and how to correctly document.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(5) · Plan of correction due date: Jul 31, 2024

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. . 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.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Licensee agrees to cease pre-pouring medications immediately. Licensee shall schedule an in-service training and submit names of those attended.

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, May 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312 · Plan of correction due date: May 16, 2024

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: 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.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: 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.

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Questionable death due to neglect.

Licensing Program Analysts (LPAs) Sarena Keosavang and Cheyenne Ratajczak arrived at the facility unannounced 12/27/2023 to deliver findings for a complaint Community Care Licensing (CCL) received on 07/21/2023. LPA met with Business Office Manager, Jennette Mariano, and explained the purpose of the visit. The Department requested pertinent documents relevant to the complaint investigation such as, resident (R1) physician's report, identification and emergency information, death report, eMAR, admission agreement, assessments, medical records, Metro Fire PCR, Devilbiss 5-litre Oxygen Concentrator instruction guide, policy and procedures to oxygen use for residents, policy and procedures for use of pulse oximeter, staff training or in-service records, SOC 341, staff roster and schedule, and Apria records. Continue on LIC9099-C. Unsubstantiated On 07/19/2023, Emergency Medical Services (EMS) Personnel were dispatched to Cogir of Stock for a resident (R1) with shortness of breath. Upon arrival at the facility EMS personnel observed that R1’s oxygen concentrator was turned off. Two (2) EMS personnel reported that they heard staff (S1) state the machine had been turned off the prior night because it was beeping. S1 was asked about a back-up oxygen tank and nasal cannula was not in place. S1 stated they had called for a new machine and were told one would be delivered the next day. S1 told EMS, “We didn’t know what else to do.” The Department interviewed and received statements from a total of eleven (11) facility staff and two (2) residents. Interview statement received from S1 indicated that the concentrator was alarming on 07/18/2023, and S1 called Apria Health Care to request a new concentrator. S1 made inconsistent statements about when S1 first noticed R1’s oxygen concentrator was turned off and cannula not in place, before calling 911. When S1 was first interviewed, S1 stated R1’s oxygen was off and nasal cannula was not in place when S1 first checked on R1. During a follow-up interview, S1 stated did not remember noticing R1’s nasal cannula and only recalled being aware of the concentrator being off during the second medication passing, when S1 discovered R1 having shortness of breath and calling 911. S1 denied telling EMS that the machine had been turned off and stated S1 had later assumed that the overnight shift must have turned the machine off. Multiple staff were interviewed, and all denied turning the machine off. Interview statement received from overnight staff (S2) admitted that the machine had been alarming and had quit working sometime early in the night, but that S2 had been able to reset the concentrator to get it working again. Medical records obtained and witness statements provided that R1 had been previously diagnosed and treated for ST-Elevation Myocardial Infarction in June 2023. It was noted that R1 had a history of chronic respiratory failure. Medical personnel were interviewed and stated it would be difficult to determine if a lack of supplemental oxygen preceded or contributed to R1’s death. R1’s pronouncing physician was interviewed and stated R1’s respiratory failure could have happened for several reasons, regardless of R1 being on or off oxygen. Therefore, there is not sufficient evidence to substantiate the allegation of wrongful death. Based on the Department’s investigation as stated above, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Dec 27, 2023 · control 59-AS-20230721111141

Allegation investigated: Staff are not providing adequate food service to residents.

On 11/30/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 10/10/2023. LPA met with Executive Director (ED), Ricky David, and explained the purpose of the visit. During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complaint investigation.According to the interview statement received, the facility’s kitchen was in disrepair. Due to the kitchen being in disrepair staff were not providing adequate food service to residents in care. The Department received interview statements from a total of four (4) facility staff. All four staff indicated staff provided adequate food services to residents in care. Staff were able to provide food to residents promptly. The kitchen was flooded with soap water after dinner was over and meals were served to residents in care. Due to the information above, CCL finds the allegation to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was left at the facility. Unsubstantiated Allegation: Licensee is not ensuring facility kitchen is kept clean. – Unfounded. The Department received an interview statement from the complainant indicating that the facility’s kitchen was in disrepair. ED and upper management asked kitchen staff to produce food in an unsafe environment. The Department conducted interviews and received statements from a total of four (4) facility staff. It was discovered the kitchen was in disrepair on 10/09/2023 at approximately 8:30 PM. Interview statement received from staff (S1) indicated that kitchen staff was done prepping/cooking the food for residents in care before the kitchen was in disrepair. Interview statement received from S2 indicated, staff would clean kitchen twice a day from 2 PM and 7 PM. The floors are mopped and swept once a day. Interview statement received from S3 indicated kitchen was not dirty while staff were prepping and cooking food for residents in care. Everything was clean except the floor. There was soap water on the floor. The kitchen was flooding with water after dinner around 8 PM. Interview statement received from ED indicated that it was not a sewage issue. There was clear water coming from the dishwasher machine. ED notified Regional Vice President Operation the same day at approximately 8:30-9:00 PM. Regional Vice President Operation was present at the facility after being notified to help clean the kitchen and hired Blue Team to sanitize the kitchen. The Department requested a repair invoice for review. According to Blue Team Daily Field Report, the first responder cleaned and sanitized affected kitchen flooring on 10/10/2023. Blue Team inspected nearby walls and found no moisture. Allegation: Licensee is not addressing sewage problem at facility. – Unfounded. The Department conducted interviews and received statements from a total of four (4) facility staff. It was discovered that the facility’s kitchen was in disrepair on 10/09/2023. Interview statement received from ED indicated that it was not a sewage issue. There was clear water coming from the dishwasher machine. ED notified Regional Vice President Operation the same day at approximately 8:30-9:00 PM. Regional Vice President Operation was present at the facility after being notified to help clean the kitchen and hired Blue Team to sanitize the kitchen. The Department requested a building permit and repair invoice for review. The building permit indicated the facility was being billed for plumbing permit. According to Blue Team Daily Field Report, the first responder cleaned and sanitized affected kitchen flooring on 10/10/2023. Blue Team inspected nearby walls and found no moisture. The Department received the Heating and Air Design Corporation invoice for review. The Heating and Air Design Corporation have furnished the material and performed the labor necessary for the completion of: 1. Removal/replacement of a 4 “main kitchen drain line approximately 93 feet long to the main 6” in the hallway by bursting method. 2. Concrete-saw and dug two (2) additional connections in the kitchen for new connections for the employee’s bathroom and walk-in floor drain. 3. Floors drain behind steamer will be abandoned due to connection is under the walk-in freezer box. This line will be attached to far wall with ¾” copper tubing to drain to ice machine floor drain. 4. Library will need to be tented and the concrete floor saw cut 3’x5’ to access common area bathroom tie-ins. 5. Approximately 30’ of hallway will need to be tented and evacuation plans rerouted around the front area. 6. First priority is to dig down in all areas to affected pipe areas and attachments. 7. Put in shoring safety in for every 4’ and deeper. 8. Realign entire branch line by the bursting method/ensure grease trap has been drained. 9. First attach branch line to hallway line to continue flow and work backwards connecting common bathrooms, floor drain for walk-in freezer, employee bathroom, and outside grease trap line. 10. Leave open for a day to check for any leaks. 11. Start backfilling from kitchen to main hallway drain. Compact fill and have a concrete truck pump concrete back and contractor do smooth finish. 12. Remove all tenting after two (2) days of curing. Have a team come and clean all affected areas. The Department requested Citrus Heights Police Department, Code Enforcement Officer, to conduct a joint visit to the facility with LPA Keosavang on 10/19/2023. The Code Enforcement Officer received a work order from the facility and the case has been closed. The Department received interview statement from Blue Team inspector. Inspector stated the repairs took 13 days. It was discovered that the facility did their due diligence and addressed the issue by hiring outside vendors for repairs in a timely manner. Allegation: Licensee does not ensure the facility has working toilets. – Unfounded. The Department conducted interviews and received statements from a total of four (4) facility staff. Interview statements received from all four staff indicated the bathroom in the staff break room is currently out of order. All four staff indicated there are other bathrooms in the facility that are available for staff to use. Interview statement received from ED indicated that all residents in care have a bathroom in their rooms. The only toilets that weren’t working were the toilets in the staff’s break room. No residents’ toilets were jeopardized. ED state staff can use any other bathroom. The facility has a couple of vacant rooms with bathrooms that staff can use. The Department received interview statement from Blue Team inspector. Inspector indicated toilet in staff's break room were out of service along with one common area bathrooms. The facility opened bathrooms down the hall from the common area bathroom. The toilets in the break room and common area was repaired in 7 days. Based on records reviewed, facility observations and interviews, all the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit Interview conducted. A copy of this report has been provided to the facility. No citations have been issued during today's visit.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 59-AS-20231010105714

Allegation investigated: Staff do not assist residents with showering.

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. Substantiatedthe state’s words, verbatim · CDSS document, Nov 2, 2023 · control 59-AS-20230926154214

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 9, 2023

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 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.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: Facility to submit in written plan of understanding regulation section 87464 by POC due date 11/09/2023.