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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002954
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:52:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20231108090803
FACILITY NAME:IVY PARK OF ROSEVILLEFACILITY NUMBER:
315002954
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:140CENSUS: 119DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not prevent facility from being hazardous leading to resident suffering a fall while in care.
Staff attempted to administer a medication that fell on the floor to a resident in care.
Staff did not keep facility free of mold.
Staff did not respond to resident's request for a meal replacement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Chad Rogers during today’s inspection.
LPA investigated allegation, “Staff did not prevent facility from being hazardous leading to resident suffering a fall while in care”. LPA conducted interviews, file reviews, and toured resident room. LPA interviewed resident in which they stated that upon move in they observed a large warp in the flooring in their bathroom. They informed the facility about this, but while waiting for the floor to be fixed they had a fall and hurt their hand. Resident stated they did not seek medical attention or inform the facility nurse. Resident stated their physical therapist(PT) from an outside agency was aware of the injury.

Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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 8
Control Number 59-AS-20231108090803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: IVY PARK OF ROSEVILLE
FACILITY NUMBER: 315002954
VISIT DATE: 01/10/2024
NARRATIVE
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Resident was unable to provide LPA the contact information for PT and LPA was unable to interview. LPA interviewed a staff member from the maintenance team in which they stated there was a very small bubble in the flooring of the bathroom. Staff stated they don’t believe it was a tripping hazard but they did replace the whole bathroom floor. LPA observed a receipt from an outside agency for 10/4/23, in which company replaced the entire bathroom floor. LPA reviewed the work orders from maintenance, in which it shows the staff became aware of the flooring issue on 09/21/23. LPA interviewed the Health Services Director in which she stated she was unaware of any fall or trip hazard in resident room. LPA finds the allegation to be UNSUBSTANTIATED.

LPA investigated allegation, “Staff attempted to administer a medication that fell on the floor to a resident in care.” LPA interviewed resident in which they stated a medication technician (med tech) was dispensing their medications in the dining room. Med tech dropped resident pill on the ground and then proceeded to wipe off the pill and offer resident their medication. Resident was unable to provide LPA the name of the med tech. LPA interviewed health services director and she stated staff informed her that one time med tech handed resident their medications and resident dropped it on the floor and then resident picked it up off the ground and resident took it. Due to conflicting information LPA finds the allegation to be UNSUBSTANTIATED.

LPA investigated allegation, “Staff did not keep facility free of mold.” LPA interviewed resident in which they stated that there was mold in their shower. Resident informed the maintenance team and they confirmed the mold and removed it. LPA interviewed maintenance staff in which he stated he did observe mold in resident room, but he did observe dirt in the shower divider. Staff stated they cleaned the area and replaced the shower divider. LPA toured the facility and did not observe mold in the facility. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED.

Continuation on 9099-C.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20231108090803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: IVY PARK OF ROSEVILLE
FACILITY NUMBER: 315002954
VISIT DATE: 01/10/2024
NARRATIVE
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LPA investigated allegation, “Staff did not respond to resident's request for a meal replacement.” LPA interviewed resident in which they stated there were many issues with the kitchen. Resident stated many times the kitchen staff did not serve them the food they ordered. Resident stated they are allergic to melon and strawberries and the fruit was served to them on multiple occasions for breakfast. The kitchen staff refused them a meal replacement and just grabbed the melon from their plate instead. LPA interviewed kitchen staff and they stated there were a couple of times during the morning shift that resident was served melon with their breakfast food. The resident informed the kitchen staff and staff immediately replaced their food with no melon on their plate. Kitchen staff did not recall a time where staff grabbed the melon off the plate and refused a meal replacement. Due to the conflicting information 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.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20231108090803

FACILITY NAME:IVY PARK OF ROSEVILLEFACILITY NUMBER:
315002954
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:140CENSUS: 119DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not ensure that facility repairs are completed in a timely manner.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Chad Rogers during today’s inspection.
LPA investigated allegation, “Staff did not ensure that facility repairs are completed in a timely manner.” LPA conducted a file review and conducted interviews. LPA interviewed resident in which they stated they had many issues with the physical facility and needed items fixed frequently. Resident stated they informed administrator frequently of the maintenance issues that needed to be fixed and they rarely received a response. LPA interviewed maintenance staff member, in which they stated they had to document the work orders and when it would be completed. Staff stated they tried to fix the maintenance issues that came up from the resident with urgency.
Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 59-AS-20231108090803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: IVY PARK OF ROSEVILLE
FACILITY NUMBER: 315002954
VISIT DATE: 01/10/2024
NARRATIVE
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 If the issue required a 3rd party, it did take longer than normal. LPA reviewed the work orders, and observed 18 completed work order tasks. All work orders were completed within a few days or within the week. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, “Facility is in disrepair.” LPA conducted a file review, interviews, and toured the facility. LPA interviewed the resident in which they stated there were many issues with the maintenance of the facility which included the doors not locking properly, the garbage area, elevator, and their room having multiple issues during their stay. LPA toured the facility which included resident room, common living spaces, kitchen, elevators, and dining room. LPA observed the facility to be in good repair. LPA reviewed the work orders and found resident had 18 work orders while residing within the facility. All work orders were resolved. LPA observed that there were several maintenance issues that came up, however all issues were resolved in a timely manner. Due to the information gathered LPA finds the allegation to be UNFOUNDED.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20231108090803

FACILITY NAME:IVY PARK OF ROSEVILLEFACILITY NUMBER:
315002954
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:140CENSUS: 119DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff is not following resident’s dietary plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Chad Rogers during today’s inspection.
LPA investigated the allegation, “Facility staff is not following resident’s dietary plan”. LPA conducted file reviews, and interviewed staff and residents. LPA interviewed resident in which they stated that the facility kitchen served melon on their plate, and the facility was aware that they were allegoric to melon. LPA reviewed resident documents and found on the LIC602 dated 8/22/23 it states resident is allegoric to “Lisinopril, NSAIDs, Melon, Walnuts, Almond Oil, Latex, Peanut-containing drug products, strawberry”. LPA reviewed the document, “Diet clarification request”, and it states the only diet resident receives is the “no added salt”.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 59-AS-20231108090803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: IVY PARK OF ROSEVILLE
FACILITY NUMBER: 315002954
VISIT DATE: 01/10/2024
NARRATIVE
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LPA interviewed kitchen staff in which they stated there were a couple of times during the morning shift that resident was served melon with their breakfast food. The resident informed the kitchen staff and staff immediately replaced her food with no melon on their plate. Kitchen staff stated resident’s allergy to melon was not listed in the dietary restriction binder in the kitchen that lists diets and allegories. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D.

Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20231108090803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: IVY PARK OF ROSEVILLE
FACILITY NUMBER: 315002954
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87555(a)
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(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Administrator agrees to place a dietary restriction board in a common place in the kitchen for staff to review. Administrator to send LPA a picture of the board onced placed in the kitchen. POC due by 1/31/24.
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This requirement is not met as evidenced by: Based on interviews and record review the licensee did not ensure resident was served safe food which poses a potential health, and safety risk to resident's in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8