347001903-1-4-2022-27-AS-TTRG-CACS2G-20220104122932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001903
Report Date: 01/04/2022
Date Signed: 01/04/2022 12:29:40 PM

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 RETIREMENT HOME		FACILITY NUMBER:	347001903
ADMINISTRATOR:	JOSHIKA PRASAD		FACILITY TYPE:	740
ADDRESS:	2030 23RD STREET		TELEPHONE:	(916) 455-8849
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95818
CAPACITY:	36	CENSUS: 20	DATE:	01/04/2022
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Jennifer Hobbs		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/4/2022 at 10:13 am, Licensing Program Analysts (LPAs) Tung Truong and Anthony Tuck arrived at this facility unannounced to conduct an annual inspection visit. Upon LPAs arrival, facility staff contacted Jennifer Hobbs who arrived a bit later. LPA met with Jennifer Hobbs explained the purpose of today’s visit. Administrator holds current certification #6016989740 and expires on 8/7/2022. There are currently twenty (20) residents who reside at this facility. LPA toured the facility with Jennifer Hobbs on 1/4/2022 at 10:40 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry rooms, medication room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water measured in the restrooms and resident’s bathroom were above 120 degrees Fahrenheit which are not within the required range of 105-120 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. Medications, toxins, and knives were inaccessible to residents. Smoke detectors are present in every room and throughout the facility. Facility also has carbon monoxide detectors. Fire extinguishers and first aid kit were up to date. LPA also conducted the infection control domain tool. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: IVY RIDGE RETIREMENT HOME	FACILITY NUMBER: 347001903
	VISIT DATE: 01/04/2022

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The facility mitigation plan was submitted to CCLD, and it was approved on 4/26/2021. Facility has routine symptom screening checks for residents, staff, and visitors. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:

(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC309 Administrative Organization

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited on 809-D. An exit interview was held, a copy of this report 809-D and Appeal Rights were provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 RETIREMENT HOME	FACILITY NUMBER: 347001903
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not maintained water temperature between 105 and 120 degrees F. The water sink temperature was at 123.6 degrees F. & the resident’s bathroom sink temperature was at 124.3 degress F. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 01/05/2022
	Plan of Correction
1 2 3 4	Licensee and LPA agree to: Submit letter stating knowledge of, understanding of regulation 87303(e)(2). Correction due 1/5/2022. LPA notes Administrator adjusted temperature. Licensee agrees to hold in-service training detailing importance of regulation 87303(e)(2). Letter and training log due to CCL as proof of correction. LPA is further requesting log of water temperatures taken one time a day for 3 days, to ensure water temperature is within 105-120 degree range.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC809 (FAS) - (06/04)

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