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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701234
Report Date: 12/13/2023
Date Signed: 12/14/2023 03:16:48 PM

Document Has Been Signed on 12/14/2023 03:16 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:KITNIKONE, SUNNIEFACILITY TYPE:
740
ADDRESS:2030 23RD STTELEPHONE:
(916) 600-3309
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY: 36CENSUS: 26DATE:
12/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Pak Wu and Hong TrinhTIME COMPLETED:
02:30 PM
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A virtual Informal conference was conducted today on 12/13/2023 at 1:30 PM via Microsoft Teams. The purpose of the meeting is to discuss complaint findings and non-compliance concerns issued to facility # 347001903 while Ivy Ridge Care, Inc. was managing the facility which closed as of April 14, 2023, due to change of ownership. A new license has been issued to Ivy Ridge Care, Inc.#342701234. Present in the meeting are Licensing Program Manager Czarrina Camilon-Lee, and Licensing Program Analyst Pang Lee, Licensing Program Analyst Tung Truong, Licensee Pak Wu and administrator Hong Trinh. The informal conference process was explained during this meeting.

During today’s meeting we discussed the administrator certification renewal. It was learned that administrator Hong Trinh renewal was not on the pending application list or the active certificate list. Licensee Pak Wu stated that he will follow-up with the Administrator Certification Section (ASC). LPA Lee will provide Licensee the Administrator Certification contact information.

The following concerns were discussed:
·Three questionable death that was substantiated from previous change of ownership in November 2022, facility license number 347001903.
·The facility was issued 10 type A citations and 2 type B citations since 04/13/2023.
·Resident AWOL
·Insufficient staffing in the facility
·Monitoring residents for change of condition.
·Notifying the physician or calling 9-1-1 when medical attention is needed.

The facility has stated they have and will do the following to achieve continued and substantial compliance:
· Licensee stated they has terminated 90% of old staff and hired new staff for the facility.
Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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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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: 12/13/2023
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·The facility has implemented employee meetings which are held once a month. The meeting consists of training staff on monitoring and supervising changes in residents’ condition, Title 22 regulations, observe and prevent open wound.
· The facility has implemented a manager’s meeting held once a week.
· The facility has implemented that during every staff shift staff are required to submit a written report to administrator Hong Trinh and then the report will be placed in residents’ file.
· The facility has implemented that House Manager, Lezel Bello whovwill ensure to visually observe residents on a daily basis.
· The facility will ensure that all staff are compliant with all required training.
· The facility will ensure to conduct training for all staff on monitoring and identify for changes in residents’ conditions and seek medical attention.
· The facility will ensure that all staff are clear on the requirements and responsibilities of their jobs.
· The facility will conduct training for all staff on how to redirect residents to prevent AWOL.
· The Facility Administrator will ensure the compliance plan is always followed.
· The facility will submit LIC 500 Personnel Report and LIC 308 Designated Responsibility to LPA Lee

Licensee Pak Wu and Licensee/Administrator Hong Trinh reported all facility plans to achieve compliance will be submitted to the Community Care Licensing Department by December 27, 2023, by 5:00 PM. The licensee was advised failure to follow the agreed plan could result in a Non-Compliance Conference. No deficiencies were cited during today's meeting. An exit interview was conducted with facility representatives Licensee Pak Wu and Licensee/Administrator Hong Trinh. A copy of this report was provided on 12/14/2023.



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

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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