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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701234
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:53:51 AM

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
08/14/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240814165808
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: 35DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lezel BelloTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Licensee is encouraging staff to falsify documentation regarding residents in care.
Licensee does not ensure that residents are provided with activities while in care.
INVESTIGATION FINDINGS:
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On 11/07/2024 at 10:22 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Administrator Lezel Bello 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 35. A brief interview with Lezel was conducted.

It was alleged that licensee is encouraging staff to falsify documentation regarding resident’s care. This investigation consisted of records review and interview with facility staff. To investigate, LPA Lee conducted a review of resident records and interviewed facility staff. LPA Lee reviewed the files of five residents and found no indication to show that the facility staff falsified resident documentation regarding their care. 5 out 5 residents were interviewed to compare resident services to what was written on documentation. LPA found no discrepancies between the care that was provided stated by residents to the resident care plan.

Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 6
Control Number 27-AS-20240814165808
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: 11/07/2024
NARRATIVE
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 Additionally, LPA Lee interviewed 5 facility staff members, all of whom denied the allegations of document falsification. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations.

It was alleged that licensee does not ensure that residents are provided with activities while in care. The investigation included observations, a review of records, and interviews with both facility staff and residents. On 10/07/2024, LPA Lee observed a facility staff member leading an exercise activity in the common area with the residents. A review of the facility’s records confirmed the presence of a monthly activity calendar, detailing daily events. Additionally, six out of seven residents interviewed denied the allegations, confirming that activities are provided regularly. They also stated that they are aware of the activity calendar’s location and were able to describe activities such as bingo, news discussions, movie nights, exercise sessions, and singing. LPA Lee also interviewed 5 facility staff members, all of whom denied the allegations and reported that there are three activities per day. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations.

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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
08/14/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240814165808

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: 35DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lezel BelloTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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9
Staff are mismanaging residents’ medications.
Staff are not administering medications to residents according to physician's instructions.
Facility is odiferous.
INVESTIGATION FINDINGS:
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On 11/07/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Administrator Lezel Bello 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 35. A brief interview with Lezel was conducted.

An allegation was made that staff are mismanaging residents' medications and not administering medications to residents according to physicians' instructions. The investigation included a review of records, auditing of resident medications, and interviews with facility staff and residents. A review of the Medication Administration Records (MARs) revealed discrepancies in 7 out of 8 resident logs. On 08/19/2024, LPA Lee, Ombudsman Suhair, Med-Tech Lydia, Administrator Hong Trinh, and Administrator Assistant Lezel conducted a medication audit for eight residents.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 6
Control Number 27-AS-20240814165808
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: 11/07/2024
NARRATIVE
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 Along with facility staff, LPA compared and reviewed medication count to medication administration record and found that resident 1 (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered. The Med-Tech staff acknowledged the discrepancy at the time of audit and explained that the missing 14 pills may have not been accounted for when R1 was admitted to the facility 07/15/2024. Additionally, LPA Lee interviewed 3 out of 7 residents, who reported that they had not received their medications from the Med-Tech staff as prescribed. Based on the interviews and evidence gathered during the investigation it was found that the facility staff are mismanaging and not administering medication as prescribed to residents in care.

An allegation was made that the facility is odiferous. The investigation included observations and interviews with residents and staff. On 08/19/2024, LPA Lee, Ombudsman Suhair, Administrator Hong Trinh, and Licensee Pak Wu toured the Terrance Hall. It was observed a strong urine odor in resident room #24. Additionally, a mild urine odor was noted in resident room # 27. Interviews with 4 out of 7 residents revealed that the upstairs area of the Terrace building does has a strong urine odor. Based on the observations and resident interviews, LPA Lee was able to corroborate the allegation.

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. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240814165808
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2024
Section Cited
CCR
87465(c)(2)
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87465(c)(2): Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN….
(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidence by:
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Administrator will complete Incidental Medical and Dental Care in-service training. Administrator will provide training materials and sign in sheet of staff trained. POC will be emailed to LPA Lee by 11/14/2024 end of day 5:00 PM.
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Based on observation, medication review and interview (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered; therefore, resident’s medication were mismanaged. This posed an immediate potential health, safety, and personal rights risks to residents in care.
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Type A
11/14/2024
Section Cited
CCR
87465(c)(3)
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87465(c)(3) Incidental Medical and Dental Care

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN….
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidence by:
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Administrator and Med-techs will review regulation 87465 Incidental Medical and Dental Care and provide LPA Lee a statement of acknowledgement and understanding of the regulation cite. POC due to LPA by 11/14/2024 end of day 5:00 PM
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Based on observation, medication review and interview (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered therefore, resident’s medication is not being administered per physician’s order. This posed an immediate potential health, safety, and personal rights risks 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240814165808
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2024
Section Cited
CCR
87625(b)(3)
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5:00 PM
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.

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Administrator will conduct a Managed Incontinence In-service training. Administrator will provide LPA Lee training materials and sign in sheet to LPA Lee. Administrator will also provide a statement of acknowledgment of understanding of regulation. POC due by 5:00 PM 11/14/2024.
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This requirement is not met as evidence by:
Based on observation and interviews It was observed a strong urine odor in resident room #24. Additionally, a mild urine odor was noted in resident room # 27. This posed a potential health, safety, and personal rights risks 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6