342701234-2-22-2024-27-AS-KHOS-D34NCN-20240306092101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701234
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:22:07 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
01/23/2024 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240123145354

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: 28	DATE:	02/22/2024
		UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Tanisha Linzy		TIME COMPLETED:	03:31 PM

ALLEGATION(S):

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Facility does not have an administrator.
Staff does not maintain a resident's room in an organized and clean fashion.
Facility has pests.

INVESTIGATION FINDINGS:

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On 02/21/2024 at 12:57 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Med-Tech Tanisha Linzy and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 28. A brief interview with conducted with designated staff Hong Trinh via telephone.

Allegation: Facility does not have an administrator.
It was alleged that the facility does not have an administrator. This investigation consisted of interviews with facility staff and residents. LPA Lee interviewed 10 out of 10 residents who confirm that they don’t know and have never seen administrator Sunnie Kitnikone. In addition, 10 out of 10 residents referred Zoe and Lezel as the administrator to the facility. On 01/26/2024 licensee Pak Wu admitted that Sunnie Kitnikone is a friend of his, who also owns her own residential facility. Licensee explained that Sunnie Kitnikone was added as the administrator to this facility since designated staff Hong Trinh’s administrator certificate had expired.
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: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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 27-AS-20240123145354

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: 02/22/2024

NARRATIVE

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Both licensee and designated staff Hong Trinh confirmed that Sunnie Kitnikone holds the administrator title for the facility only and that Sunny Kitnikone has no involved in the operations of the facility.
As a result, this 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. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations

Allegation: Staff does not maintain a resident's room in an organized and clean fashion.

It was alleged that the staff does not maintain a resident's room in an organized and clean fashion. This investigation consisted of observations and interviews. LPA Lee interviewed 4 out of 10 residents who confirm that the facility staff does not help residents maintain the cleanliness of their rooms. During a complaint visit on 01/26/2024 LPA Lee toured the facility and observed 11 resident bedrooms. LPA Lee observed bedroom #9 to appear clean and organized; however, LPA Lee observed the toilet in bedroom #9 to be dirty and unsanitary. (R1) did confirmed that more cleaning assistant is needed in (R1)’s bathroom. Moreover, on 01/26/2024 LPA Lee observed resident’s bedrooms #23 and #24 had a very strong urine odor. On 01/26/2024, LPA Lee also observed resident’s bathroom #1 and #2 up stairs in the main building to be unsanitary and dirty.

As a result, this 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. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations

Allegation: Facility has pests.

It was alleged that the facility has pests. This investigation consisted of observations and interviews. During the complaint visit on 01/26/2024 LPA Lee toured the facility with licensee Pak Wu and designated staff Hong Trinh and it was observed that resident bedroom #4 had two live bed bugs on the mattress and sheet cover. In addition, LPA Lee, licensee Pak Wu and designated staff Hong Trinh observed dead bed bugs in the upstairs bathroom #2.

As a result, this 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 is substantiated; however, there will be no deficiencies cited since this allegation was also substantiated and cited on 12/14/2023.

An exit interview was conducted with Tanisha Linzy and a copy of this LIC 9099, LIC 9099-C, LIC 9099-D page and appeal rights was given to Tanisha Linzy.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240123145354

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: 02/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/01/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all the following personal rights: (2)To be accorded safe, healthful, and comfortable accommodations furnishings and equipment. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to ensure that all rooms are cleaned throughout the day. Licensee also hired an extra floater to help with the cleanliness of the facility. Resident bedroom #23 and 24 will be inspect and clean weekly.
	8 9 10 11 12 13 14	Based on observation and interviews the licensee did not ensure that resident’s rooms and bathrooms clean and sanitary for residents in care. This poses a potential health and safety to residents in care.	8 9 10 11 12 13 14	Licensee will email LPA Lee room cleaning schedule log for the month of February. POC will be email to LPA Lee by 03/01/2024 by 5:00 PM.
Type B 03/01/2024 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to ensure that an administrator that is associated to the facility is on the premises and provide adequate attention to manage the facility. Licensee will read regulation cited and write a statement of acknowledgement. POC will be email to LPA Lee by 03/01/2024 by 5:00 PM.
	8 9 10 11 12 13 14	Based on interviews, the Licensee did not ensure that the facility has an active administrator on the premises to provide adequate attention to manage the facility. This poses a potential health and safety to residents in care.	8 9 10 11 12 13 14

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: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC9099 (FAS) - (06/04)

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