347001903-12-20-2022-27-AS-CACL-CNCT8G-20230123133019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001903
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:24:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20220308102303

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: 29	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Hong Trinh		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide timely medical attention to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 12/20/22 to deliver the complaint findings with the allegations mentioned above. LPA met with Administrator Hong Trinh and discussed the purpose of the visit and the elements of the allegation(s).

The allegation of staff did not provide timely medical attention to resident, the Department finds sufficient evidence to support the allegation. According to medical records, R1 was diagnosed with severe sepsis with acute organ dysfunction among other diagnosis when admitted. It was deemed that R1 has suffered over several days of worsening delirium prior to hospital visit. It was learned that facility staff reported to Alpha One staff that R1 has been increasingly altered, complained of all-over body pain and had not eaten or taken medication for two days.

Report continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 7

Control Number 27-AS-20220308102303

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2022

NARRATIVE

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As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview conducted, a copy of this report, LIC 9099-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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20220308102303

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:	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Hong Trinh		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide pain medication as prescribed
Staff did not safeguard resident's property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 12/20/22 to deliver the complaint findings with the allegations mentioned above. LPA met with Administrator Hong Trinh and discussed the purpose of the visit and the elements of the allegation(s).

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Regarding the allegation of staff did not provide pain medication as prescribed, LPA did not find any evidence to support the allegation. Based on records review, administering pain medication is not in scope of facility practice. Facility staff is not to provide pain medication to residents. Pain medication is managed by hospice staff.

Continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 27-AS-20220308102303

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2022

NARRATIVE

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The allegation of staff did not safeguard resident's property, LPA did not find any evidence to support the allegation. Based on review of facility theft and loss policy and R1's admission agreement, the facility is not responsible for the theft or loss of personal property. The facility also does not handle R1’s money. Moreover, R1’s Physician’s report revealed that R1 was unable to manage their own cash resources.

This Department has investigated the allegations noted above and has found that the allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or was without a reasonable basis.

Exit interview was conducted and a copy of the report was 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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20220308102303

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:	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Hong Trinh		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care
Staff did not notice change in residents condition
Staff did not notify resident's representative of change in condition

INVESTIGATION FINDINGS:

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2
3
4
5
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7
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9
10
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12
13

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 12/20/22 to deliver the complaint findings with the allegations mentioned above. LPA met with Administrator Hong Trinh and discussed the purpose of the visit and the elements of the allegation(s).

The investigation was conducted by the Department which consisted of reviews of records and interviews. The allegation that resident sustained a pressure injury while in care, the Department did not find sufficient evidence to support the allegation. Based on medical records, it was unclear/unspecify that resident (R1) acquired a pressure injury upon arrival. Hospice staff and facility staff denied seeing any pressure injuries on R1 prior to R1 going to ER.

Report continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 27-AS-20220308102303

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2022

NARRATIVE

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The allegation that staff did not notice change in residents condition, the Department finds insufficient evidence to support the allegation. The complaint alleged that facility staff did not notice that R1 has pressure injury. Based on statements obtained, facility staff and hospice nurse denied seeing any pressure injuries on R1.

The allegation that staff did not notify resident's representative of change in condition, the Department finds insufficient evidence to support the allegation. Based on statements obtained, facility staff has called 9-1-1 and notify R1’s POA when R1 was being transfer to ER. Moreover, facility staff stated that they did not observe any injuries on R1.

As a result of this investigation, this Department found the allegations above to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report was 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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 27-AS-20220308102303

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/21/2022 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee/Administrator shall submit a plan of correction on how the facility will be in compliance with regulation 87465(g) at all times to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the regulation cited above by not seeking timely medical attention for R1 which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 7