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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701234
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:52:09 PM


Document Has Been Signed on 04/03/2024 03:52 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:IVY RIDGE ASSISTED LIVINGFACILITY NUMBER:
342701234
ADMINISTRATOR:HONG TRINH (ZOE)FACILITY TYPE:
740
ADDRESS:2030 23RD STTELEPHONE:
(916) 600-3309
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 30DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Pak Wu and Hong TrinhTIME COMPLETED:
04:00 PM
NARRATIVE
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On 04/03/2024 at 8:21 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Tanisha Linzy, who then called administrator, Hong Trinh. Administrator and Licensee arrived approximately an hour later. LPA Lee explained the purpose of the visit. The Licensee and Administrator assisted with today’s visit. Administrator certificate # is 6042113740 and will expire on 12/4/2024. The current census is 30 residents with 7 facility staff which consist of 1 housekeeper, 1 Med-tech, 2 caregiver, 2 cook and the administrator and licensee.

This facility is a two story building licensed to serve thirty-six (36) non-ambulatory residents, which 4 may be bedridden and approved for 2 hospice waivers. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedroom, residents’ bathroom, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be clean and in good repair. LPA Lee observed the back facility, Terrence Hall to have a strong urine odor as LPA Lee entered the building. The urine order was noticeable upstairs and downstairs of the building. In addition, when LPA Lee toured the Terrence building LPA Lee observed the following residents’ room to have a very strong urine odor: residents bedrooms number # 14, 20, 21, 27 and 24. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee toured the kitchen and observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 114.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety.
Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 04/03/2024 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA Lee reviewed 5 resident MAR logs and 5 out of 5 logs was missing staff initials. LPA Lee also audit the medication and 2 out of 5 resident medications was either not given to resident or the medications are missing. This poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee/Administrator agrees to review the regulation cited today and provide a statement of understanding and acknowledgement of the regulation cited. Licensee/Administrator will also conduct a medication training to all Med-Techs and provide LPA Lee of the training materials used and a sign in and out sheet by POC date of 04/19/2024 by end of day. Licensee stated that they are switching binder MAR Logs to "Alcomy" a digital tracking system to track medication being dispense to residents by 04/15/2024.
Type A
Section Cited
CCR
87468.1
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above. LPA Lee observed the back Terrence Building to have strong urine odor. LPA Lee observed 5 residents’ room to have a strong urine odor which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee/Administrator agrees to change all garbage without lids to garbage with lids. Licensee/Administrator will conduct daily cleaning, check, and empty garbage twice a day. Bedding will be washed daily to ensure there is no odor. During today's visit Licensee purchased 30 garbage can with lid. Licensee will send pictures once the garbage’s arrives. Licensee/Administrator agrees to review the regulation cited today and provide a statement of understanding and acknowledgement of the regulation cited. The cleaning and washing scheduled will also be emailed to LPA Lee by POC date 04/19/2024.
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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 04/03/2024 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
87625(b)(3) Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above. LPA Lee observed the back Terrence Building to have strong urine odor. LPA Lee observed 5 residents’ room to have a strong urine odor which poses an potential health, safety, or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee/Administrator agrees to change all garbage without lids to garbage with lids. Licensee/Administrator will conduct daily cleaning, check, and empty garbage twice a day. Bedding will be washed daily to ensure there is no odor. During today's visit Licensee purchased 30 garbage can with lid. Licensee will send pictures once the garbage’s arrive. The cleaning and washing scheduled will also be emailed to LPA Lee by POC date 04/19/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/03/2024
NARRATIVE
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The fire extinguisher is located in the kitchen and common area and was last serviced on 12/22/2023. LPA Lee observed the facility has a has a public telephone in the kitchen and office. The facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee observed toxins located in laundry and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to resident. LPA Lee along with Med-Tech Tanisha Linzy reviewed and compared 5 medication administration record (MAR) and it was not complete. MAR logs was missing staff initials. LPA Lee and Med-Tech Tanisha also audit 2 resident medications and it was learned that the medication is either not given to residents or are missing. The first aid kit was checked and contained all the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 10 resident files and four resident's LIC 625 are missing resident's signature. LPA Lee reviewed 3 staff files, and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents were given to LPA during today's visit.
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 610 Emergency Disaster Plan
(3) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5