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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701234
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:09:02 PM

Unsubstantiated


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
12/08/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231208105830
FACILITY NAME:IVY RIDGE ASSISTED LIVINGFACILITY NUMBER:
342701234
ADMINISTRATOR:KITNIKONE, SUNNIEFACILITY TYPE:
740
ADDRESS:2030 23RD STTELEPHONE:
(916) 600-3309
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 29DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Ernie Inductivo and Tanisha LinzyTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff does not maintain resident’s hygiene.
INVESTIGATION FINDINGS:
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On 02/02/2024 at 1:37 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Ernie Inductivo and explained the purpose of the visit. Care staff called designated person in charge, Hong Trinh, who stated she won't be able to join the visit. LPA Lee explained the purpose of this visit is to deliver complaint findings for the allegations above to both Hong Trinh and Ernie Inductivo. The census is 29.

Allegation: Staff did not maintain residents’ hygiene.
It was alleged that staff did not maintain residents’ hygiene. This investigation consisted of records reviewed, observations, interviews with staff and residents. LPA Lee interviewed 9 out of 9 residents and 7 out of 9 residents have no concerns with staff not maintaining residents’ hygiene. On 12/14/2023 during a complaint investigation LPA Lee observed 10 residents in the common area and the 10 residents appeared to look clean.
Continued LIC 9009-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 5
Control Number 27-AS-20231208105830
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: 02/02/2024
NARRATIVE
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 LPA Lee also observed (S1) assisting residents with incontinence care. In addition, on 01/26/2024 during a complaint visit LPA Lee observe all the residents that LPA Lee interviewed appeared to be cleaned. LPA Lee also observed (S1) assisting residents with incontinence care. In addition, LPA Lee reviewed shower logs for the month of November 2023 to January 2024 and records review revealed that residents are getting incontinence care.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/08/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231208105830

FACILITY NAME:IVY RIDGE ASSISTED LIVINGFACILITY NUMBER:
342701234
ADMINISTRATOR:KITNIKONE, SUNNIEFACILITY TYPE:
740
ADDRESS:2030 23RD STTELEPHONE:
(916) 600-3309
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 29DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Ernie Inductivo Tanisha LinzyTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not present to provide care and supervision to residents.
Staff did not provide resident with linens.
INVESTIGATION FINDINGS:
1
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3
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5
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7
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9
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13
On 02/02/2024 at 1:37 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Ernie Inductivo and explained the purpose of the visit. Care staff called designated person in charge, Hong Trinh, who stated she won't be able to join the visit. LPA Lee explained the purpose of this visit is to deliver complaint findings for the allegations above to both Hong Trinh and Ernie Inductivo. The census is 29.

Allegation: Staff are not present to provide care and supervision to residents.
It was alleged that staff are not present to provide care and supervision to residents. This investigation consisted of records reviewed, observations, interviews with staff and residents. LPA Lee interviewed 9 out of 9 residents and 6 out of 9 residents have concerns regarding staff does not providing care and supervision to residents in care. In addition, on 01/26/2024 at 8:15 AM, LPA Lee observed one staff in the kitchen with the kitchen glass door locked while 15 residents were observed in the common area with no facility staff present.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 5
Control Number 27-AS-20231208105830
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: 02/02/2024
NARRATIVE
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It was learned that on 01/26/2024 staff 1 (S1) had left the facility due to a family emergency. It was also learned that the (S1) did not inform the licensee and administrator before leaving the facility. As a result, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met

Allegation: Staff did not provide residents with linens.

It was alleged that staff did not provide residents with linens. This investigation consisted of records reviewed, observations, interviews with staff and residents. LPA Lee interviewed 9 out of 9 residents and 3 out of 9 residents stated that facility staff did not provide residents with linens. On 12/14/2023 during a complaint visit LPA Lee observed resident bedroom #27A missing a fitted sheet. In addition, on 01/26/2024 during a complaint visit, LPA Lee also observed resident bedroom #24 did not have a fitted sheet. As a result, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was given to the facility.



Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.
A copy of this report was provided, along with Appeal Rights and LIC 811, the Confidential Names List.
Exit interview.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231208105830
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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) (f) and Health and Safety Code section 1569.2(i).

This requirement is not met as evidenced by:
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Licensee agrees to conduct care and supervision training for all staff and submit a written care plan on how the facility will provide adequate care and supervision to all residents. POC will be email to LPA Lee by POC date 02/09/2024 by the end of day 5:00 PM.
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Based on interviews and observations the licensee did not ensure care and supervision needs were provided. LPA Lee observed 15 residents in the common area with no facility present. This poses/posed an immediate health and safety risks to resident in care.
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Type B
02/16/2024
Section Cited
CCR
87307(a)(3)(C)
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87307(a)(3)(C) Personal Accommodations and Services
a) Living accommodations and grounds shall be related to the facility's function…
(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillowcases, mattress pads…

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Facility will provide training to staff regarding room checks to ensure that all residents have the adequate linens needed. POC will be provided to LPA Lee by POC date of 02/16/2024 by end of day 5:00 PM

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This regulation was not met as evidence by:
Based on observations and interview the licensee did not ensure that a provision of clean linens was available to each resident. Based on documentation two resident was observed with no sheets on their bed. This poses a potential 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5