347001903-1-27-2023-27-AS-TTRG-CNGTCL-20230127133655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001903
Report Date: 01/27/2023
Date Signed: 01/27/2023 01:37:00 PM

Document Has Been Signed on 01/27/2023 01:37 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 LIVING		FACILITY NUMBER:	347001903
ADMINISTRATOR:	TRINH, HONG		FACILITY TYPE:	740
ADDRESS:	2030 23RD STREET		TELEPHONE:	(916) 455-8849
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95818
CAPACITY:	36	CENSUS: 27	DATE:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Hong Trinh, Administrator		TIME COMPLETED:	01:50 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	Licensing Program Analyst (LPA) Tung Truong conducted an unannounced 1 Year Annual Inspection Visit on 1/27/2023. LPA met with Administrator Hong Trinh and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator Certificate # 6042113740 expires 12/04/22. Renewal application was received on 12/8/2022 and currently showing pending. The facility had COVID -19 posters and signs throughout the facility. The facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. Medication room was toured. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. Kitchen was toured for adequate food supplies and storage. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured and is within the required range of 105-120F. The temperature inside the facility measured at 74F which was within the required range of 68-85*F. 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: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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

FACILITY NAME: IVY RIDGE ASSISTED LIVING	FACILITY NUMBER: 347001903
	VISIT DATE: 01/27/2023

NARRATIVE

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LPA observed the fire extinguisher(s) and first aid kits were up to date. Smoke and carbon monoxide detector(s) in the facility were in good repair. LPA and Administrator tested the emergency pull cord system and it was in good repair. LPA also conducted the infection control domain tool.

LPA requested resident and staff files for review. LPA reviewed (4) resident files and (4) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

Licensee 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) Updated LIC610 Emergency Disaster Plan
(5) Current Liability Insurance

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. Exit interview held, copy of report given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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