315002954-2-21-2024-59-AS-KHOS-D32PHN-20240304102012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002954
Report Date: 02/21/2024
Date Signed: 02/21/2024 11:26:14 AM

Unfounded

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
12/20/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20231220093910

FACILITY NAME:	IVY PARK OF ROSEVILLE		FACILITY NUMBER:	315002954
ADMINISTRATOR:	PRYOR, JESSICA		FACILITY TYPE:	740
ADDRESS:	5161 FOOTHILLS BLVD.		TELEPHONE:	(916) 780-3330
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	140	CENSUS: 116	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Chad Rogers, Administrator		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Facility is not abiding by the admissions agreement.
Facility staff are not allowing residents to have visitors.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Chad Rogers during today’s inspection.
LPA investigated the allegation, “Facility is not abiding by the admissions agreement”. LPA obtained copies of admission agreement, resident invoices, and other pertinent documents. Reporting party stated resident was being charged for meals to be delivered to resident room which was against the admission agreement. Resident
LIC602 states resident is ambulatory and does not require help while feeding themselves.. LPA reviewed resident invoices and observed resident was being charged for rent, care fees, guest meals, and tray service monthly.

Continuation on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231220093910

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: 02/21/2024

NARRATIVE

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LPA reviewed resident admission agreement in which it states, “Ivy Park will provide room service to your apartment during a temporary illness, at no extra charge, not to exceed three days a year. During other times optional room service will be provided to you at your request for an extra charge”.In addition, admission agreement states, there will be an extra fee for guest meals. LPA interviewed administrator in which he stated there is a fee for food being delivered to resident room. Due to the information gathered LPA finds the allegation to be UNFOUNDED.

LPA investigated the allegation, “Facility staff are not allowing residents to have visitors.” LPA obtained copies of resident’s documents and conducted interviews. LPA interviewed relevant parties in which they stated facility allows visitors for the resident during business hours but they are not allowing overnight visitors to stay with the resident. LPA interviewed administrator in which he stated that the facility will allow overnight visitors with the prior approval of the administrator, and it can only be for a short period of time. Administrator stated resident was allowing their granddaughter to stay the night without the approval of the facility or any type of notification. Administrator stated he sent a letter to the resident and their responsible party in October 2023 stating resident’s granddaughter was not permitted to stay the night in resident room without the permission of the facility. LPA reviewed the admission agreement in which it states, “Before any visitor stays in your apartment overnight you must notify the executive director in writing. All visitors must register at the front desk when entering the community.” Due to the information gathered, LPA finds allegation to be UNFOUNDED.

Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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