342701234-5-18-2023-27-AS-KHOS-CSCJ6B-20230531064603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701234
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:49:38 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/09/2023 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20230509151348

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:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Hong Trinh		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not provide proper medication assistance to resident in care
Staff did not provide proper food service to resident in care

INVESTIGATION FINDINGS:

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On 5/18/2023, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to conclude the investigation of the above allegation and to deliver the findings. LPA met with Licensee Hong Trinh and explained the purpose of today’s visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and records review, the allegations mentioned above were deemed unfounded. Resident (R1) corroborated that facility staff have provided medication timely and food services is adequate. LPA Truong conducted a review of R1’s MAR, Insulin MAR, and Blood Glucose Reading Log and observed that R1's did receive medication as prescribed by R1's physician.

As a result of this investigation, LPA finds the allegations above to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis.
An exit interview was conducted, and a copy of this report was left at the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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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