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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701234
Report Date: 05/06/2026
Date Signed: 05/08/2026 09:05:33 AM

Document Has Been Signed on 05/08/2026 09:05 AM - 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/
DIRECTOR:		LEZEL BELLOFACILITY TYPE:
740
ADDRESS:2030 23RD STTELEPHONE:
(916) 600-3309
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY: 36CENSUS: 36DATE:
05/06/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lezel BelloTIME VISIT/
INSPECTION COMPLETED:
04:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on May 06, 2026, at 2:00 PM. LPA met with Lezel Bello and explained the purpose of the visit.

The purpose of the visit today, is follow up on learned deficiencies. The facility did not ensure medications were made inaccessible to residents in care. LPA Martinez observed two unlocked first aid kits that stored medication. The facility has a first aid kit cabinet located next to the main entry door. This first aid cabinet was unlocked and had ANSI A Ointment, Tripple Antibiotic, First Aid Burn Cream. The facility also has a first aid kit located at the resident exterior patio. This first aid kit lock was not in good repair. The first aid kit had the following medications, medicated Medi Honey bandages, first aid burn cream, and antibiotic cream.

Additionally, it was learned that resident 1 (R1) was not provided basic services. R1 was left in soiled briefs for an extended period of time and developed skin integrity problems. R1 also has red skin and skin tears on a private part area of their body. R1 has had the skin tears for approximately two days. It was also learned care staff did not inform the Administrator that R1 had skin tears and did not report this change in condition to R1's primary care physician.

Based on the above learned information, the facility will cited the following 87464 (f)(1) Basic Services and 87465 (h)(2) Incidental Medical and Dental Care. An immediate health and safety civil penalty shall be assessed on May 06, 2026 in the amount of $500.00 for the violation of 87465 (h)(2) Incidental Medical and Dental Care. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An Exit interview was conducted and 809 report and appeal rights and LIC 421 were given to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/08/2026 09:05 AM - It Cannot Be Edited


Created By: Avelina Martinez On 05/06/2026 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IVY RIDGE ASSISTED LIVING
FACILITY NUMBER: 342701234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2026
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees.
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Facility staff agrees to email LPA Martinez Incidental and Medical and Dental in-service agenda by 05/07/2026 by 5:00 PM. Facility staff agrees to conduct in-service training by 05/20/2026. Facility Staff agrees to email in-service training document to LPA Martinez by POC date 05/20/2026 5:00 PM
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This requirement was not met as evidence by.Based on observation, inspection, and interviews, the Licensee did not ensure medication were kept in a safe locked place and made inaccessible to residents in care. This posed an immediate health and safety risk to residents in care.
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Type A
05/07/2026
Section Cited
CCR87464(f)(1)

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Basic Service 87464(f)(1):(f) Basic services shall at a minimum include:Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: based on
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Facility staff agrees to report R1's change in condition to their primary physician by 05/07/2026. Facility staff agrees to conduct a reassessment and include incontinence care plan for R1 by 05/08/2026. Facility Staff agrees to email LPA Martinez Assessment and incontinence care documentation by poc
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observation and interviews, the Licensee did not ensure to provide basic service to R1's and address R1's skin integrity/skin tears. This poses an immediate health and safety risk to R1.
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date 05/08/2026 by 5:00 PM. Facility staff agrees to email LPA Martinez skin integrity/skin tear reporting information to LPA Martinez by 05/07/2026 by 5:00 PM
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
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