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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701234
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:12:10 PM


Document Has Been Signed on 11/20/2023 04:12 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 28DATE:
11/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Hong TrinhTIME COMPLETED:
04:30 PM
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On 11/20/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. LPA met with Administrator Hong Trinh and explained the purpose of the visit.

The purpose of this case management visit is to follow up on information obtained from a complaint investigation conducted by the Department. Complaint control number: 27-AS-20221223104058.

The following was discussed with the Administrator:
- Staff must report to the Administrator to seek approval before sending residents to the hospital.
- Residents reported that they were not always receiving medication.
- Someone was doing resident's tax and resident's refund check went missing.
- Hoyer lift use/training.
- Residents received Insulin administration not by nurse.

Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. The administrator was advised that LPA would return at a later date to complete the investigation.

An exit interview was held, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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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