342701234-3-24-2023-27-AS-TTRG-CQ8QVE-20230324123012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701234
Report Date: 03/24/2023
Date Signed: 03/24/2023 12:30:50 PM

Document Has Been Signed on 03/24/2023 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	IVY RIDGE ASSISTED LIVING		FACILITY NUMBER:	342701234
ADMINISTRATOR:	KITNIKONE, SUNNIE		FACILITY TYPE:	740
ADDRESS:	2030 23RD ST		TELEPHONE:	(916) 600-3309
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95818
CAPACITY:	36	CENSUS: 29	DATE:	03/24/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Hong Trinh		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA met with Applicant Pak Wu and Hong Trinh and explained the purpose of the visit. Designated Administrator Sunnie Kitnikone was also present. Facility has a fire clearance for 4 bedridden residents and 32 non-ambulatory residents. Hong Trinh will be the Administrator of this facility once her administrator certificate is renewed. Designated Administrator Sunnie Kitnikone holds current administrator certificate # 6037853740 which will expire on 4/18/2024. The facility has a current census of 29 residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. Hot water temperature was observed to be 115 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 70 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. Weekly fire alarm check and water temperature log were observed. Report Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: IVY RIDGE ASSISTED LIVING	FACILITY NUMBER: 342701234
	VISIT DATE: 03/24/2023

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The Infection Control Plan has been submitted. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. Hand Hygiene procedures have been implemented. LPA requested client and staff files for review. LPA reviewed (4) resident files and (3) staff files. Hong Trinh will oversee new resident admission.

Component III was waived. The Administrator has completed Component III from another licensed facilities. Based on a review of this facility during this pre-licensing visit, it was determined that this facility was found to be in compliance at this time. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. Final approval of the license by the Applications Analyst is pending. Exit interview conducted, and a copy of this report was given to the applicant.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

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