Cogir of Stock Ranch.

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.

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.

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.

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) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.

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.

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.

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

On 8/23/20233, R1 moved out of the community. ED stated R1's bedroom was cleaned and provided pictures. LPA did not tour R1's bedroom due to the bedroom has been cleaned and was not in its original state. R1 is no longer living at the facility. LPA received interview statement from a total of four (4) facility staff. Statements from all four (4) staff were consistent. R1 bedroom was a "mess" and refused cleaning services. Interview statement received from S2 indicated, housekeeper is scheduled to clean residents rooms every once a week; however, housekeeper has been cleaning R1's room twice a week. LPA received interview statement from R1's responsible party (RP). RP stated the allegation is not true and that R1 refuses services from staff. Allegation: Resident room is malodorous. - Unsubstantiated. LPA received interview statement from a total of four (4) facility staff. Interview statement from three (3) staff indicated, R1's room is not malodorous and does not smell like urine or feces. Interview statement from S4 indicated, R1's room smells like urine and feces depending on which week it is, but housekeeper has not missed a cleaning day. Interview statement received from R1's RP indicated, R1 refuses staff to assist with toileting and showers. RP and facility head nurse had a meeting and a plan in place for R1. Head nurse suggest for R1 to participate by letting staff provide services and assist but R1 refuses. Based on 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.