312700263-2-15-2023-25-AS-KHOS-CPAR9V-20230222115010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700263
Report Date: 02/15/2023
Date Signed: 02/15/2023 03:20:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20230104094318

FACILITY NAME:	IVY PARK OF ROSEVILLE		FACILITY NUMBER:	312700263
ADMINISTRATOR:	JESSICA PRYOR		FACILITY TYPE:	740
ADDRESS:	5161 FOOTHILLS BLVD		TELEPHONE:	(916) 780-3330
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	0	CENSUS: 105	DATE:	02/15/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lisa Downs, Front of House Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff not responding to residents call button in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to deliver complaint findings regarding the above allegation. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.
During investigation LPA toured the facility, interviewed staff and residents, and reviewed documentation. LPA interviewed 6 staff members in which they stated AM shift has 4 to 5 caregivers and 2 med techs, PM shift has 4 caregivers and 2 med techs, and the night shift has 1 med tech and 2 caregivers. At times staff stated there are call offs and there are not as many caregivers as planned which impacts their response time to the resident call button. Additionally staff stated if they are providing care to a resident, they can not leave their current resident and so the resident pressing their call button may wait longer periods of time until they can respond
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20230104094318

FACILITY NAME:	IVY PARK OF ROSEVILLE		FACILITY NUMBER:	312700263
ADMINISTRATOR:	JESSICA PRYOR		FACILITY TYPE:	740
ADDRESS:	5161 FOOTHILLS BLVD		TELEPHONE:	(916) 780-3330
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	0	CENSUS: 105	DATE:	02/15/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lisa Downs, Front of House Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff does not provide nutritious meal(s).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to deliver complaint findings regarding the above allegations. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.
During the complaint investigation LPA toured the facility including the kitchen area, interviewed residents, and interviewed staff. LPA toured the kitchen and looked inside of the refrigerator, freezer, and pantry area. LPA observed 2-day perishable and 7-day non-perishable amount of food per requirement. LPA observed a variety of fruits and vegetables available for residents. LPA reviewed facility menu and observed a variety of meals with fresh vegetables and fruits being served. LPA interviewed 5 residents in which they stated vegetables and fruits are provided however they would prefer more of a variety.
Due to the information gathered, LPA finds allegations to be be unfounded. Exit interview conducted and copy of report given.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20230104094318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: IVY PARK OF ROSEVILLE	FACILITY NUMBER: 312700263
	VISIT DATE: 02/15/2023

NARRATIVE

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Care staff state they try to respond in a timely manner to resident calls, but at times it can take longer then normal. LPA interviewed 5 residents in which they stated they can wait long periods of time for care staff to respond to their call buttons. Some days it can take long periods of time for staff to respond and other days the staff respond in a timely manner. All residents stated they have not had an emergency situation occur due to waiting for staff to respond to their call button.

Due to the information gathered, LPA finds that residents can wait long periods of time for staff to respond but not consistently and no emergency situations have occurred due to residents waiting for staff. LPA finds allegation to be unsubstantiated.Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was provided to facility administrator.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC9099 (FAS) - (06/04)

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