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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002954
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:04:31 AM

Substantiated


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
01/02/2024 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20240102141144
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: 120DATE:
03/06/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff do not ensure residents are monitored for early signs of illness while in care.
Staff do not ensure infection control requirements are followed.
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, “Staff do not ensure residents are monitored for early signs of illness while in care”. LPA interviewed reporting party in which they reported residents signs and symptoms to facility staff, and staff informed reporting party that resident had to purchase their own covid test. Reporting party stated they purchased a covid test, returned to the facility, and resident tested positive for Covid.

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: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
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 4
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
01/02/2024 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20240102141144

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: 120DATE:
03/06/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff do not ensure sufficient care and supervision is provided for residents
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 allegation, “Staff do not ensure sufficient care and supervision is provided for residents”. Relevant party had concerns that the facility staff were not checking on resident while they were covid positive and in isolation. LPA reviewed resident documents and reviewed resident care notes. Staff documentation shows that staff checked on resident several times throughout the day and night while resident was in isolation. LPA interviewed resident in which they stated staff checked on them several times a day while they were in isolation. Due to the information gathered LPA finds allegation to be UNFOUNDED.
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: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
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 4
Control Number 59-AS-20240102141144
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: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2024
Section Cited
CCR
87465(a)(9)
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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (9) The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements.
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Administrator to complete training with all staff concerning infection control policies and regulations. Copy of training to be sent into CCL by 3/25/24.
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This requirement is not met as evidenced by: Based on record review and interviews the licensee did not follow facility plan which poses a potential health and safety risk to residents in care.
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Type B
03/25/2024
Section Cited
CCR
87470(b)(2)
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87470 Infection Control Requirements. (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply:(2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.
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Administrator to complete training with all staff concerning infection control policies and regulations. Copy of training to be sent into CCL by 3/25/24.
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This requirement is not met as evidenced by: Based on interviews the licensee did not follow infection control plan which poses a potential health and safety risk to residents 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: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20240102141144
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: 03/06/2024
NARRATIVE
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LPA interviewed administrator in which he stated staff did inform reporting party that resident needed to purchase their own covid test. LPA reviewed facility infection control plan and policies. LPA observed the following, “Oakmont will perform testing for residents in the following situations: Within 48 hours after the development of COVID symptoms". Due to the information gathered LPA finds allegation to be SUBSTANTIATED.

LPA investigated allegation, “Staff do not ensure infection control requirements are followed.” LPA interviewed reporting party in which she stated that once resident tested positive, resident was in isolation in their room. There was PPE set up outside the resident room, and staff were made aware that PPE was needed when entering the resident room. Reporting party stated a staff member entered the resident room with no PPE on and delivered resident their meal. LPA interviewed administrator in which he stated a staff member did enter resident room without proper PPE. 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.

Copy of report provided to the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4