342701234-9-4-2025-27-AS-CACL-DLKUUN-20250916155348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701234
Report Date: 09/04/2025
Date Signed: 09/04/2025 09:56:19 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
09/27/2024 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240927142723

FACILITY NAME:	IVY RIDGE ASSISTED LIVING		FACILITY NUMBER:	342701234
ADMINISTRATOR:	HONG TRINH (ZOE)		FACILITY TYPE:	740
ADDRESS:	2030 23RD ST		TELEPHONE:	(916) 600-3309
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95818
CAPACITY:	36	CENSUS: 36	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Lezel Bello		TIME COMPLETED:	10:16 AM

ALLEGATION(S):

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Due to staff neglect, resident sustained a pressure injury
Staff retained a resident with a prohibited health condition

INVESTIGATION FINDINGS:

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On 09/04/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with facility designated administrator (FDA) Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 36. A brief interview was conducted with FDA Bello.

It was alleged that due to staff neglect, resident sustained a pressure injury and that staff retained a resident with a prohibited health condition. This investigation consisted of records reviewed, interviews with staff, residents, and outside agencies. It was learned that on 9/25/2024, at approximately 2012 hours, resident 1 (R1) was admitted to Sutter Medical Center Sacramento Emergency Room (ER) for a chief complaint of a stage three pressure ulcer of the sacral region. Multiple staff reported R1 did not have any mobility issues and did not require assistance with transferring, repositioning, or toileting.

CONTINUED LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240927142723

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: 09/04/2025

NARRATIVE

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Staff stated R1 requires stand-by assistance with the shower. Multiple staff confirmed interacting with R1 in the days leading up to the discovery of the pressure injury and denied R1 had any changes in condition or signs to indicate a skin breakdown. Staff denied R1 verbalized any pain until 9/25/2024, the day R1 was sent out to the hospital. Moreover resident 1 (R1) reported that the pressure injury occurred at the hospital, not at the facility. R1 stated they did not believe the injury was present before hospitalization, as they felt no pain prior but began experiencing pain while lying in the hospital bed. R1 also mentioned they independently handle their own showers. An outside agency (OA) representative, during an interview, expressed no concerns about R1 developing a pressure injury at the facility. OA observed R1 using the toilet independently and managing personal hygiene. On 09/10/2024, OA noted that R1 was walking around, had intact skin, and vital signs were within normal limits. OA also assisted R1 with perineal care that day and observed no redness or signs of pressure injury. OA had no concerns regarding the adequacy of R1’s care at the facility. OA confirmed R1 was not receiving home health services for a pressure injury. OA assessed R1 prior to discharge from home health and did not observe an injury. Staff 1 (S1) acknowledged being present when R1 took a shower on 9/23/2024 as a stand-by assist to prevent R1 from falling. S1 asked R1 if R1 wanted help, but R1 refused and showered him/herself. S1 and multiple staff denied seeing a pressure injury at any time during care. R1’s records corroborated the staff’s statements that R1 was independent with care and ambulatory. R1 was on home health from 7/24/2024 to 9/10/2024. Based on the interviews conducted during the investigation and records reviewed the department 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: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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