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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001903
Report Date: 04/06/2023
Date Signed: 04/06/2023 04:11:29 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
01/20/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230120134926
FACILITY NAME:IVY RIDGE ASSISTED LIVINGFACILITY NUMBER:
347001903
ADMINISTRATOR:TRINH, HONGFACILITY TYPE:
740
ADDRESS:2030 23RD STREETTELEPHONE:
(916) 455-8849
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 28DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hong TrinhTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility does not ensure planned social activities are provided for residents
INVESTIGATION FINDINGS:
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On 4/6/2023 at 9:00 am, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the complaint investigation and deliver the findings. LPA met with Administrator Hong Trinh and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on observation and interviews, it was determined that the facility did not ensure planned activities were made available to residents. Residents interviewed described little to no planned or posted activities in the home. Moreover, Administrator confirmed to LPA that a notice of planned activities was not previously posted on prior visit.

Per regulations, the facility shall post planned activities and encourage residents to maintain and develop their fullest potential for independent living through participation in planned activities.

Report continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
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-20230120134926
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: 04/06/2023
NARRATIVE
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As a result of this investigation, the Department finds the allegation 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 was conducted with Administrator Hong Trinh, a copy of report, LIC 9099-D, and appeal rights provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230120134926
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: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2023
Section Cited
CCR
87219
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Planned Activities: (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities(d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location.
This requirement is not met as evidence by:
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Administrator will make and post a calendar with planned activities for residents. Administrator will also ensure there is one designated staff responsible for daily activities. Administrator will submit proof of this to LPA by 04/12/2023.
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Based on observation and interviews, the licensee did not ensure planned activities were made available to residents. LPA observed no posted activities schedule and residents interviewed described little to no planned or posted activities in the home, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3