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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002954
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:02:43 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
03/18/2024 and conducted by Evaluator Bethany Mirlohi
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240318090507
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: 119DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Danette Fadollone, Business Office DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not provide adequate supervision, resulting in a resident wandering away from the facility unsupervised.
Staff did not ensure that facility front door alarm was working.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Business Office Director Danette Fadollone during today’s visit. LPA spoke to Administrator over the phone.
LPA investigation allegation, “Staff did not provide adequate supervision, resulting in a resident wandering away from the facility unsupervised.” LPA obtained resident records and conducted interviews with staff and relevant party. Relevant Party indicated on March 15th at approximately 2 PM, they arrived at the facility to pick up R1 for a doctor’s appointment. Relevant Party reported they found R1 wandering in the facility parking lot unsupervised. Relevant party reported that facility was unaware resident was wandering outside the facility until she reported the incident.
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: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 3
Control Number 59-AS-20240318090507
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: 05/01/2024
NARRATIVE
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LPA interviewed staff member who works near the front door. Staff stated R1 wears a wander guard, but staff did not hear an alarm go off and did not see R1 leave the facility. Staff stated she was alerted by relevant party that R1 was outside wandering. Record review indicated that R1 was placed on the wanderguard system due to R1 having an increase in confusion. Wanderguard consent form was sign by R1’s responsible party on 2/14/24 and wanderguard bracelet was placed on R1’s walker. Due to the information gathered LPA finds allegation to be SUBSTANTIATED.
LPA investigated allegation, "Staff did not ensure that facility front door alarm was working."LPA obtained resident records and conducted interviews with staff and relevant party. Relevant Party indicated on March 15th at approximately 2 PM, they arrived at the facility to pick up R1 for a doctor’s appointment. Relevant Party reported they found R1 wandering in the facility parking lot unsupervised. Relevant party reported that facility was unaware resident was wandering outside the facility until she reported the incident. LPA interviewed staff member who works near the front door. Staff stated R1 wears a wander guard, but staff did not hear an alarm go off and did not see R1 leave the facility. Staff stated she was alerted by relevant party that R1 was outside wandering. LPA interviewed staff in which he stated he helped fix the wanderguard system. Staff stated that sensors were set on a low setting and due to R1 wearing their wanderguard bracelet on the walker, the sensors did not pick up the signal. Staff have updated the wanderguard system so sensors are on high and whenever a wanderguard gets within 6 feet, the alarm will signal. Administrator stated he is checking the wanderguard system weekly in precaution. Although the wanderguard system was in working order, the facility did not ensure the R1’s location of the wanderguard was placed properly to ensure wanderguard sensors would work properly. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

Deficiencies cited on 9099-D. Appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20240318090507
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: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
HSC
1569.312
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§1569.312 Basic services requirements. (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community.
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Administrator stated the facility will be conducting elopement drills monthly with care staff. Administrator to send into LPA a copy of documentation of the first elopement drill.
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Based on interviews and record review the licensee did not provide adequate supervision which resulted in resident wandering away from facility which poses a potential health and safety risk to residents in care.
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Documentation to be sent into CCL by 5/22/24.
Type B
05/22/2024
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Administrator to send LPA plan on how wanderguard will be checked to be in working order for all residents with the wanderguard system. Plan to be submitted into CCL by 5/22/24.
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Based on interviews and record review the licensee did not ensure wanderguard alarm system was working correctly 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: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3