347001903-3-8-2023-27-AS-CACL-CPYSTZ-20230316141022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001903
Report Date: 03/08/2023
Date Signed: 03/08/2023 02:45:22 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
02/28/2023 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20230228121731

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:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Hong Trinh		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Due to lack of supervision, resident eloped from the facility

INVESTIGATION FINDINGS:

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On 3/8/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation with the allegation above. LPA met with Administrator Hong Trinh and explained the purpose of the visit.

During the course of the investigation, LPA conducted interviews and reviewed records. Based on the interviews conducted and reviewed of records, it was learned that on 2/28/23 resident (R1) awoled out of the back door of the facility that did not have egress or chime on the door. Based on staff statement, R1 has a history of exit seeking and although the staff knew the resident left and attempted to follow; the staff stated a car had blocked her view of where the resident was and eventually lost visual track on resident. It was learned that there were no 1 on 1 supervision and/or safety measures in place to prevent R1 from awoling.

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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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 3

Control Number 27-AS-20230228121731

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 ASSISTED LIVING	FACILITY NUMBER: 347001903
	VISIT DATE: 03/08/2023

NARRATIVE

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Based on interviews conducted, and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations.

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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230228121731

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 ASSISTED LIVING	FACILITY NUMBER: 347001903
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/09/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met by:	1 2 3 4 5 6 7	The Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall submit the in-service training materials and plan of correction on how facility will ensure residents do not AWOL and sent a signature sheet of all staff who attended to LPA by POC date.
	8 9 10 11 12 13 14	Based on interviews and record review. The Licensee did not ensure adequate supervision of residents in care. R1 AWOL'd from the facility. This poses an immediate health and safety risk to the resident in care.	8 9 10 11 12 13 14
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	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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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