Most inspections at Cogir of Stock Ranch found no deficiencies, with several complaint investigations determined to be unsubstantiated. The most recent report from February 11, 2025, noted no deficiencies but included two minor technical violations related to an elevator permit display and a medication order discrepancy that was promptly addressed. Earlier reports identified some deficiencies primarily involving medication management, documentation, and a substantiated issue with missed resident showers due to staffing shortages. A serious safety concern was cited in May 2024 when a resident left the facility unassisted, posing an immediate health risk, but no fines or enforcement actions were listed in the available reports. The facility’s record shows some improvement over time, with the latest inspection clean except for minor technical issues.
The inspection was an unannounced required 1-year inspection conducted to evaluate compliance with licensing regulations at Cogir of Stock Ranch.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and health regulations. No deficiencies were cited during the inspection, although a technical violation was noted for one elevator permit not being displayed and a medication order discrepancy was identified and addressed with education to the administrator.
Severity Breakdown
Technical Violation: 2
Deficiencies (2)
Description
Severity
One out of two elevator permits not displayed in the elevators (LIC 9102-Technical Violation).
Technical Violation
Discrepancy in medication orders for one resident (LIC 9102-Technical Violation).
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-08-14 alleging that the facility did not update Needs and Services Plans for residents.
Findings
The Department reviewed records and conducted interviews, including reviewing the needs and service plans for seven residents due for reassessment. The allegation was found to be unfounded as staff were actively updating the plans and the facility had a system to notify staff of reassessments.
Complaint Details
The complaint alleged that the facility did not update Needs and Services Plans for residents. The investigation found this allegation to be unfounded, meaning it was false or without reasonable basis.
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-04-15 alleging that staff did not meet resident dietary needs, did not comply with admission agreements, and did not treat residents with dignity and respect.
Findings
The investigation found that Resident #1 lived in an independent living area not licensed by Community Care Licensing and was independent without need for care or supervision. The complaint was determined to be unfounded, meaning the allegations were false or without reasonable basis.
Complaint Details
The complaint was investigated and found to be unfounded; allegations were false, could not have happened, and/or were without reasonable basis.
Report Facts
Complaint Control Number: 59Capacity: 99Census: 76
Employees Mentioned
Name
Title
Context
Laura Munoz
Licensing Program Manager
Conducted the complaint investigation and delivered findings
Cheyenne Ratajczak
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Graham Gunby
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Ricky David
Executive Director
Facility representative met during the investigation
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-03-28 alleging that staff were not meeting residents' showering needs and other resident needs.
Findings
The investigation included interviews with staff and residents and a records review. The allegations that staff were not meeting residents' showering needs and other needs were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint alleged that staff were not meeting residents' showering needs and other resident needs. Interviews revealed some showers were missed occasionally but residents sometimes showered themselves or were offered schedule changes. Staff reported challenges with staffing and pager issues affecting response times. The complaint was determined to be unsubstantiated.
The inspection visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-03-12 regarding allegations that staff did not give resident medication as prescribed and that staff illegally evicted a resident.
Findings
The investigation included interviews, record reviews, and medication audits for four residents. Both allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint involved two allegations: 1) staff did not give resident medication as prescribed, and 2) staff illegally evicted a resident. The medication audit showed medications were administered and logged correctly. Conflicting information was received regarding the eviction allegation, and it could not be proven or disproven. Both allegations were unsubstantiated.
Report Facts
Residents reviewed in medication audit: 4
Employees Mentioned
Name
Title
Context
Laura Munoz
Licensing Program Manager
Conducted the complaint investigation and delivered final findings
Cheyenne Ratajczak
Licensing Program Analyst
Conducted the complaint investigation and medication audit
The visit was an unannounced Case Management inspection conducted to follow up on deficiencies found during a medication audit performed on 03/28/2024 as part of a complaint investigation.
Findings
Deficiencies were found related to inaccurate medication documentation and improper medication storage practices, including pre-pouring medications up to four days in advance and storing them in locked cabinets accessible only to specific staff. These practices pose potential health and safety risks to residents.
Complaint Details
The visit was triggered by a complaint investigation involving a medication audit conducted on 03/28/2024, which revealed discrepancies in medication counts and improper medication handling.
Severity Breakdown
Type B: 2
Deficiencies (2)
Description
Severity
Medications were not being documented accurately, posing a potential health and safety risk to residents.
Type B
Medications are being pre-poured more than 24 hours in advance, up to four days, and stored in locked cabinets accessible only to specific staff, posing a potential health and safety risk.
Type B
Report Facts
Medication discrepancy: 2Medication discrepancy: 1Medication pre-pouring timeframe: 4Plan of Correction due date: Jul 31, 2024
Employees Mentioned
Name
Title
Context
Laura Munoz
Licensing Program Manager
Conducted the inspection and medication audit.
Cheyenne Ratajczak
Licensing Program Analyst
Conducted the inspection and medication audit.
Graham Gunby
Licensing Program Analyst
Conducted the inspection.
Ricky David
Executive Director
Facility representative met during the inspection.
The visit was an unannounced case management inspection regarding an absent without leave incident involving a resident (R1) who left the facility unassisted, contrary to physician's orders.
Findings
The facility was found deficient for failing to ensure staff awareness of residents' ability to leave unassisted, as R1 left the community unassisted posing an immediate health and safety risk. Deficiencies were cited under LIC 809-D, Title 22 Regulations.
Complaint Details
The visit was triggered by a complaint regarding an absent without leave incident reported on 05/03/2024. The complaint was substantiated as the resident left the facility unassisted against physician's report.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to be aware of the resident's general whereabouts, as R1 left the community unassisted which poses an immediate health and safety risk.
Type A
Report Facts
Deficiencies cited: 1Capacity: 99Census: 75
Employees Mentioned
Name
Title
Context
Cheyenne Ratajczak
Licensing Program Analyst
Conducted the inspection and authored the report
Ricky David
Executive Director
Met with Licensing Program Analyst during inspection
Laura Munoz
Licensing Program Manager
Supervising Licensing Program Manager named in report
The visit was an unannounced required 1-year annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulatory requirements.
Findings
The facility was found to be clean, safe, sanitary, and in good condition with appropriate staffing and required supplies. However, a deficiency was noted due to all eight staff files reviewed missing First Aid training.
Deficiencies (1)
Description
Eight out of eight staff files reviewed did not have First Aid training, posing a potential health and safety risk to persons in care.
Report Facts
Staff files missing First Aid training: 8
Employees Mentioned
Name
Title
Context
Ricky David Jr.
Executive Director
Met with Licensing Program Analyst during inspection and discussed findings
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-07-21 regarding a questionable death due to neglect at the facility.
Findings
The investigation found that the resident's oxygen concentrator was turned off prior to EMS arrival, with inconsistent staff statements about the incident. Medical records and interviews indicated insufficient evidence to substantiate the allegation of wrongful death, and the complaint was found to be unsubstantiated.
Complaint Details
The complaint alleged a questionable death due to neglect. The investigation included interviews with staff and residents, review of medical records, and EMS reports. The allegation was found unsubstantiated due to lack of sufficient evidence to prove the violation.
Report Facts
Facility capacity: 99Census: 100Number of staff interviewed: 11Number of residents interviewed: 2
Employees Mentioned
Name
Title
Context
Sarena Keosavang
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Cheyenne Ratajczak
Licensing Program Analyst
Assisted in complaint investigation
Jenette Mariano
Business Office Manager
Met with investigators during the visit and provided information
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-10-10 alleging inadequate food service, kitchen disrepair, sewage problems, and non-working toilets at the facility.
Findings
The investigation found all allegations to be unsubstantiated or unfounded. Staff interviews and documentation showed that food service was adequate despite kitchen disrepair, the kitchen flooding was due to dishwasher water not sewage, and the facility addressed plumbing repairs timely. Toilets in the staff break room were out of order but residents had working toilets. No citations were issued.
Complaint Details
The complaint alleged inadequate food service, unclean kitchen, sewage problems, and non-working toilets. The investigation found these allegations unsubstantiated or unfounded based on staff interviews, document reviews, and observations. The kitchen flooding was caused by dishwasher water, not sewage. Plumbing repairs were completed within 13 days. Staff break room toilets were out of order but residents' toilets were functional. No violations were found.
Report Facts
Capacity: 99Census: 97Complaint received date: Oct 10, 2023Inspection visit date: Nov 30, 2023Repair duration: 13Bathroom repair duration: 7
Employees Mentioned
Name
Title
Context
Ricky David
Executive Director
Met with Licensing Program Analyst during investigation and provided statements regarding kitchen and plumbing issues
Sarena Keosavang
Licensing Program Analyst
Conducted the complaint investigation visit and authored the report
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-09-26 alleging that staff do not assist residents with showering and do not meet residents' dietary needs.
Findings
The allegation that staff did not assist residents with showering was substantiated based on interviews and records indicating staffing shortages and missed showers for resident R1. The allegation regarding dietary needs was found to be unsubstantiated after review of dietary plans, interviews with staff and residents, and observation of meal services.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not assist residents with showering due to staffing shortages and missed scheduled showers for resident R1. The dietary needs allegation was unsubstantiated after investigation.
Deficiencies (1)
Description
Staff did not assist resident R1 with scheduled showers, posing a potential health and safety risk.
Report Facts
Capacity: 99Census: 99Plan of Correction Due Date: Nov 9, 2023
Employees Mentioned
Name
Title
Context
Ricky David
Executive Director
Met with Licensing Program Analyst during investigation and provided statements regarding staffing and shower scheduling
Sarena Keosavang
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Troy Ordonez
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
An unannounced complaint investigation was conducted following a complaint received on 08/22/2023 alleging that staff do not clean residents' rooms and that a resident's room was malodorous.
Findings
The investigation found the allegations to be unsubstantiated. Staff and responsible party interviews indicated that the resident refused cleaning and assistance services, and the room was cleaned after the resident moved out.
Complaint Details
The complaint alleged that staff did not clean residents' rooms and that a resident's room was malodorous. The investigation found these allegations unsubstantiated based on staff and responsible party interviews and evidence that the resident refused services.
Report Facts
Capacity: 99Census: 97
Employees Mentioned
Name
Title
Context
Sarena Keosavang
Licensing Program Analyst
Conducted the complaint investigation
Rick David Jr.
Executive Director
Met with Licensing Program Analyst during investigation
The Licensing Program Analyst arrived unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain to ensure the health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed. The facility was found to be in substantial compliance with infection control requirements. No deficiencies were cited.
Report Facts
Capacity: 99Census: 56
Employees Mentioned
Name
Title
Context
Ricky David
Executive Director
Met with Licensing Program Analyst during inspection
Unannounced complaint investigation visit conducted in response to an allegation that the facility did not protect a resident from sexual abuse.
Findings
The investigation included interviews and document reviews. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with no unusual activity observed and the criminal investigation closed without further action.
Complaint Details
The complaint alleged that the facility did not protect a resident from sexual abuse occurring on 7/12/2022. The resident reported the assault, but forensic testing found no foreign bodily fluids. Staff interviews indicated no suspicious activity. The criminal investigation was closed and the allegation was unsubstantiated by the licensing department.
Report Facts
Complaint Control Number: 25Complaint Control Number Suffix: 20220713150640
Employees Mentioned
Name
Title
Context
Michael Hood
Licensing Program Analyst
Conducted the complaint investigation and delivered findings.
Ricky David Jr.
Executive Director
Met with Licensing Program Analyst during investigation and exit interview.
An unannounced complaint investigation was conducted due to an allegation that the facility fire alarm was in disrepair.
Findings
The investigation found that the fire alarm sub panel was malfunctioning, but the rest of the panels were operable. The facility had taken due diligence by hiring a third-party company to conduct daily fire watch logs and submitted these to the Fire Department. The allegation was substantiated, but no citation was issued due to the facility's proactive measures. The facility will be monitored by the Licensing Program Analyst.
Complaint Details
The complaint was substantiated based on interviews and records reviewed. The fire alarm sub panel was found to be faulty, but the facility had implemented fire watch logs and was actively addressing the issue. No citation was issued due to the facility's due diligence.
Deficiencies (1)
Description
Facility fire alarm is in disrepair.
Report Facts
Capacity: 99Census: 64
Employees Mentioned
Name
Title
Context
Ricky David
Executive Director
Met with Licensing Program Analyst during complaint investigation and provided information about fire alarm system
Unannounced complaint investigation visit conducted due to an allegation of a questionable death at the facility.
Findings
The investigation determined that the resident in question lived in an independent living section of the facility that is not licensed or supervised by Community Care Licensing. The allegation was found to be unfounded as the independent living area does not provide care or supervision and the Department lacks authority over that section.
Complaint Details
Allegation of questionable death was investigated and found to be unfounded based on the resident living in an unlicensed independent living portion of the facility without care or supervision.
Report Facts
Capacity: 99Census: 95
Employees Mentioned
Name
Title
Context
Michael Hood
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Jenette Mariano
Business Office Coordinator
Met with Licensing Program Analyst during investigation and received report
Ricky David
Executive Director
Interviewed during investigation regarding resident living arrangements
An office meeting was held via Microsoft Teams to discuss various operational topics including improvements in operations for Cogir of Folsom, operations of the 3rd floor for Cogir of Stock Ranch, and COVID-19 vaccine booster implementation.
Findings
The report summarizes a meeting involving licensing staff and facility representatives to discuss operational improvements and COVID-19 vaccine booster implementation. No deficiencies or violations are noted in the report.
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection utilizing the infection control domain.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.
Employees Mentioned
Name
Title
Context
Tracy Daoro-Lehner
Executive Director
Met with Licensing Program Analysts during the inspection and completed the infection control domain.
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2020-10-07 regarding diabetic diets not being provided and a resident experiencing delay in physical assistance.
Findings
The investigation found the allegation that diabetic diets were not provided to be unfounded, with evidence showing appropriate dietary accommodations. The allegation of delay in physical assistance was found to be unsubstantiated due to insufficient evidence regarding the timing and staff response after a resident fall. No deficiencies were cited in either case.
Complaint Details
Two allegations were investigated: 1) diabetic diets not provided and prescribed, which was found to be unfounded; 2) a resident experienced delay in physical assistance, which was found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 99Census: 89Complaint received date: Oct 7, 2020Emergency call time: 63336Staff response time: 64113
Employees Mentioned
Name
Title
Context
Michael Reber
Evaluator / Licensing Program Analyst
Conducted the complaint investigation and authored the report
Toyin Spencer
Activity Director
Facility staff member met during investigation and recipient of report copy
Tracy Daoro-Lehner
Administrator
Facility administrator named in the report
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