342701234-12-14-2023-27-AS-KHOS-CZ6KHN-20240104065524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701234
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:39:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231204130717

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: 26	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Lezel Bello, Pak Wu and Hong Trinh		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff does not keep the facility free of pest.
staff does not maintain the facility in clean and sanitary condition.

INVESTIGATION FINDINGS:

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On 12/14/2023 at 8:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with House Manager Lezel Bello and explained the purpose of the visit. The purpose of this visit is to open and deliver complaint finding for the allegations above. The current census is 26 with 2 caregivers, 1 med-tech, 1 cook, 1 house manager and 1 maintenance staff present. At 2:45 PM, both Licensee Pak Wu and Licensee/administrator Hong Trinh arrived to the facility.

Allegation: Staff does not keep the facility free of pest.
It was alleged that staff does not keep the facility free of pest. This investigation consisted of observations, records reviewed, interviews with staffs, residents, and the resident family member. At 9:16 AM, LPA Lee toured resident 1 (R1) room. It was observed that (R1) mattress and bed sheets had numerous bed buds. LPA Lee also observed multiple bedbugs on the carpet in (R1) room. Furthermore, LPA Lee interviewed 12 residents and 7 out of 12 residents stated that they have seen bedbugs in their room. LPA Lee also spoke to administrator, Hong Trinh, who confirmed that residents in room #2, #4, #6 does have bedbugs.
Continued LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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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Control Number 27-AS-20231204130717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IVY RIDGE ASSISTED LIVING	FACILITY NUMBER: 342701234
	VISIT DATE: 12/14/2023

NARRATIVE

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Administrator also stated that she has put an order for new mattress, bed sheets and comforter for all the bedroom upstairs in the main building. It was also learned that a care staff had also witness bedbugs in resident room # 10 and #27.

Allegation: staff does not maintain the facility in clean and sanitary condition.

It was alleged that staff does not maintain the facility in clean and sanitary condition. This investigation consisted of observations, records reviewed, interviews with staffs, residents, and the resident family member. It was learned that the facility had bedbugs in 5 resident room. Furthermore, at 9:20 AM, LPA Lee observed bedbugs in the resident bathroom shower upstairs. At 12:30 PM, LPA Lee and observed the kitchen was not clean and sanitary. LPA Lee observed the kitchen stove and the range hood to be dusty and having heavy grease. LPA Lee also observed left over foods and spills on the kitchen counters.

As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with licensee and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231204130717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IVY RIDGE ASSISTED LIVING	FACILITY NUMBER: 342701234
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/28/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall have a certified pest control company conduct a facility-wide bedbug treatment. The licensee shall send proof/invoice of bedbug inspection/treatment to LPA. The licensee shall conduct routine pest control inspections
	8 9 10 11 12 13 14	Based on observation, interviews the licensee did not maintain the facility in a clean and sanitary condition. The facility currently has evidence of bedbugs. The kitchen is observed to be unclean and unsanitary. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	to minimize the outbreak of future bedbugs. The licensee shall also conduct routine cleaning to ensure that the facility at all times is clean and sanitary. Licensee will send POC to LPA Lee via email by 12/28/2023.
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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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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