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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002954
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:22:45 PM

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
08/21/2024 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20240821121518
FACILITY NAME:IVY PARK OF ROSEVILLEFACILITY NUMBER:
315002954
ADMINISTRATOR:CHAD ROGERSFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:140CENSUS: 120DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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9
Facility is retaining a resident with a higher level of care needed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver compliant findings. LPA met with Chad Rogers during today’s inspection.
LPA investigated the allegation, “Facility is retaining a resident with a higher level of care needed.” LPA interviewed staff and reviewed facility and resident documentation. Relevant party indicated that R1 had a change of condition resulting in resident requiring a 2 to 3 person assist with care. LPA interviewed staff and found R1 does require a 2-person assist and has a healing stage 1 wound. Homehealth is coming out to the facility to manage wound care. Through interviews LPA found staff are still able to meet R1’s care needs even though she is requiring more extensive care.

Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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
Control Number 59-AS-20240821121518
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: 09/26/2024
NARRATIVE
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LPA finds that although R1 does require 2 persons assist and more extensive care, R1 does not have a prohibited health condition and facility is still able to meet residents needs. Training was provided to staff on lifting techniques for R1. Due to the information gathered LPA finds 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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
08/21/2024 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20240821121518

FACILITY NAME:IVY PARK OF ROSEVILLEFACILITY NUMBER:
315002954
ADMINISTRATOR:CHAD ROGERSFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:140CENSUS: 120DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure resident's call button is answered in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver compliant findings. LPA met with Chad Rogers during today’s inspection.

LPA investigated the allegation, “Staff do not ensure resident's call button is answered in a timely manner.” LPA interviewed staff and reviewed facility documentation. Interviews with staff indicated that depending on the time of day and the care being provided, their response times vary. Staff stated there is enough staff to meet resident needs. LPA reviewed facility records concerning pendent light response times for August and September. LPA found that the average response time was approximately 10 minutes.

Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20240821121518
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: 09/26/2024
NARRATIVE
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Relevant party indicated that residents can wait long periods of time because they are instructed to respond to certain residents first. Due to the information gathered, LPA finds the 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 was conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4