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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701234
Report Date: 10/01/2024
Date Signed: 10/01/2024 10:32:03 AM

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
06/19/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230619115335
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: 35DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lezel BelloTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not properly store medications.
INVESTIGATION FINDINGS:
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On 10/1/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to deliver the findings for complaint received on 6/19/2023. LPA met with Assistant Administrator Lezel Bello and explained the purpose of today’s visit.

Throughout the course of the investigation, the Department conducted interviews and reviewed records. Based on records review, and staff and resident interviews, there is a preponderance of evidence that staff did not properly store medications. It was observed by the Department staff that medications were accessible to residents. It was learned that facility staff stored prescription medications to be administered throughout the day in a cart to save time from returning to the Medication Room on the second floor to obtain the medications. Although the cart was locked, facility staff and the administrator corroborated to the Department staff that a spare key was kept on top of the cart in a pen container and was easily assessable to anyone in the lobby, such as residents, and or visitors.

Continued on 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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-20230619115335
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: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2024
Section Cited
CCR
87465(h)(2)
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87465(h)(2). Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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Facility will provide LPA a written statement that they have reviewed and understand requirements to make medications inaccessible to residents. Licensee will conduct medication training for all staff members who administer medications and will provide training materials to LPA for review by 10/2/2024 POC date.
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Based on records reviewed, the licensee did not comply with the section cited above. The Department staff observed a spare key was kept on top of the medication cart in a pen container and was easily assessable to anyone in the lobby, such as residents, and or visitors. This poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 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
06/19/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230619115335

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: 35DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lezel BelloTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff neglect resulted in residents death.
INVESTIGATION FINDINGS:
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On 10/1/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to deliver the findings for complaint received on 6/19/2023. LPA met with Assistant Administrator Lezel Bello and explained the purpose of today’s visit.

Throughout the course of the investigation, the Department conducted interviews and reviewed records. Based on records review, and staff and resident interviews, it was learned that resident (R1) was tested positive for fentanyl and opioids on both, the day (06/15/2023) they were admitted to the hospital directly from Ivy Ridge Assisted Living, and again on the following day, 06/16/2023. Although R1 tested positive for Fentanyl, R1 did not have a prescription for it. According to records review, no residents was prescribed Fentanyl at the time, so it’s unclear how R1 came in contact with it. Residents and staff who were interviewed reported that R1 did not show any signs of being sick leading up to the day and time of the incident.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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-20230619115335
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: 10/01/2024
NARRATIVE
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According to R1’s death certificate, R1 passed away from respiratory failure and aspiration pneumonia, with drug overdose, and severe dementia listed as significant conditions that contributed to death. Final diagnosis was deemed to be poisoning by other opioids, accidental (unintentional).

As a result of this investigation, the Department finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230619115335
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: 10/01/2024
NARRATIVE
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As a result of this investigation, the Department finds the allegation above to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview conducted. A copy of report, LIC 9099-D, and appeal rights were provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5