347001903-11-20-2023-27-AS-CACL-CYASHB-20231207125316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001903
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:23:38 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
12/23/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20221223104058

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:	0	CENSUS: 28	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lezel Bello		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to deliver the complaint findings on 11/20/23 for complaint control number: 27-AS-20221223104058. LPA met with facility staff Lezel Bello and explained the purpose of the visit.

The investigation was conducted by the Department which consisted of reviews of records and interviews. The department has determined the following regarding the allegation Questionable Death (R1, R2 and R3): Staff failed to seek medical attention in a timely manner.

Continues on 9099-C, Page 2

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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 8

Control Number 27-AS-20221223104058

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: 11/20/2023

NARRATIVE

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It was learned that resident #1 (R1) was admitted to the Sutter Medical Center Intensive Care Unit (ICU) on 11/10/2022. Upon arrival, R1 was diagnosed with septic shock, UTI, influenza A, diabetic ketoacidosis, active kidney failure, and hypovolemic shock. R1’s sodium levels indicated R1 was dehydrated for more than 48 hours. Attending ICU doctor stated R1 observed in “bad shape” and that R1 would require intensive treatment. R1 passed away on 11/12/2022. A review of coroner’s report and death certificate revealed R1’s cause of death was septic shock secondary to a UTI and influenza A. Based on records review and staff interviews, staff observed R1 appeared weak and had shortness of breath multiple times over several days. Based on medical records and physician interview, there was a delay in sending the resident out for medical evaluation in a timely manner, which ultimately resulted in R1’s death.

Moreover, it was learned that resident #2 (R2) was admitted to Mercy General Hospital on 11/15/2022 for sepsis secondary to pneumonia. Upon arrival, R2 was diagnosed with acute kidney injury, diabetic ketoacidosis, and lactic acidosis. The ER doctor observed R2 to be "quite sick". R2 had sepsis if left untreated could be fatal. R2 passed away on 11/16/2022. A review of coroner’s report and death certificate revealed R2’s cause of death was cardiopulmonary arrest and pneumonia. Based on records review and staff interviews, several staff stated the Administrator was aware of R2’s change in condition and declined prior to being sent out to the hospital. Staff also acknowledged R2 had refused meals and looked weak two days prior to being sent to the hospital. Based on medical records and physician interview, it was determined that facility staff failed to seek medical attention for R2 in a timely manner, which ultimately resulted in R2’s death.

Furthermore, it was found that resident #3 (R3) was admitted to Mercy General Hospital on 11/10/2022 for altered mental status and respiratory distress. R3 passed away on 11/11/2022. A review of coroner’s report and death certificate revealed R3’s cause of death was acute hypoxemic respiratory failure and congestive heart failure exacerbation complicated by pneumonia.

Continued on 9099-C, Page 3

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

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
12/23/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20221223104058

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:	0	CENSUS: 28	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lezel Bello		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal items
Staff do not prevent residents that require supervision from leaving the facility
Staff are retaining residents that require a higher level of care
Insufficient staffing to meet resident needs
Staff yelled at resident's in care
Staff are providing care and supervision while under the influence
Staff are fraudulently recording resident records
Staff are taking resident's medications
Staff are not adequately trained

INVESTIGATION FINDINGS:

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On 11/20/23, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to deliver the complaint findings for complaint control number 27-AS-20221223104058. LPA met with facility staff Lezel Bello and explained the purpose of the visit.

Throughout the course of the investigation, LPA toured the facility, conducted staff and resident interviews and reviewed records. LPA has determined the following as it relates to the above aforementioned allegations.

Regarding the allegation that staff did not safeguard residents’ personal items, it was determined that there was insufficient evidence to substantiate that staff did not safeguard residents’ personal items.

Continues on 9099-C, Page 2

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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 8

Control Number 27-AS-20221223104058

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: 11/20/2023

NARRATIVE

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It was learned that facility staff would log resident’s property upon move-in. Staff stated that some residents opt out. Based on staff interviews, staff stated that they will help locate misplaced items and redirect residents if they try to enter a room that is not theirs.

Regarding the allegation that staff do not prevent residents that require supervision from leaving the facility, LPA finds insufficient evidence to substantiate the allegation. Based on staff interviews, staff stated that residents with exit seeking behavior are monitored at all times. It was learned that all staff members are trained to redirect residents who attempt to leave the facility. LPA observed the facility has door alarms to alert staff when resident attempts to leave the facility.

Regarding the allegation that staff are retaining residents that require a higher level of care, there is not a preponderance of evidence to substantiate the allegation. Based on staff interviews, staff stated that there were no residents who required a higher level of care residing in the facility. Staff stated that they would observe the resident for any change in condition.

Regarding the allegation that there is insufficient staffing to meet residents’ needs, LPA finds insufficient evidence to substantiate the allegation. Based on staff interviews, staff stated that there is sufficient staffing to meet residents' needs. Interviews with residents revealed that they have no concerns with care. Residents stated that they believe the facility has sufficient staffing at this time of the interview.

Regarding the allegation that staff yelled at residents in care, there is not a preponderance of evidence to substantiate the allegation. One staff reported that they had heard another staff member yelling at a resident in the past, but that staff is no longer working in the facility. LPA did not find additional information regarding this incident. Based on staff interviews, staff stated that they would only raise their voice if the resident was hard of hearing.

Continued on 9099-C, Page 3

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 27-AS-20221223104058

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: 11/20/2023

NARRATIVE

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Regarding the allegation that staff are providing care and supervision while under the influence, it was determined that there was insufficient evidence to substantiate the allegation. It was learned that a staff member was fired for drinking alcohol on her break; however, it was unclear whether this staff was intoxicated while providing care to residents.
Regarding the allegation that staff are fraudulently recording resident records, it was determined that there was insufficient evidence to substantiate the allegation. Based on staff interviews, staff S1 stated medication administration record (MAR) are recorded accurately. LPA conducted a review of two (2) residents MARs and did not find any discrepancies.

Regarding the allegation that staff are taking resident's medications, there is not a preponderance of evidence to substantiate the allegation. Based on staff interviews, staff stated they have no knowledge of any missing medications. Staff stated they did not notice any error in the medication count.

Regarding the allegation that staff are not adequately trained, there is not a preponderance of evidence to substantiate the allegation. Based on staff interviews, staff stated that they have completed training as required. LPA reviewed staff files and verified that staff training was completed.

As a result of this investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

The facility is closed. A copy of this report and appeal rights were provided to the Licensee.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 27-AS-20221223104058

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: 11/20/2023

NARRATIVE

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It was learned that R3 was last seen by Home Health Nurse on 11/9/2022 who noted that R3 should go to the emergency room for treatment. Based on medical records and physician interview, it was determined that R3 cause of death was due to a delay in medical evaluation and treatment.

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.

Due to the facility’s staff failed to seek medical attention in a timely manner, it resulted in the death of R1, R2 and R3. An immediate $1,500 ($500 for each death) civil penalty shall be assessed on November 20, 2023, for a violation of California Code of Regulations Section 87465(a)(2).

At this time, an enhanced civil penalty (ECP) was pending review and may be assessed according to Health and Safety Code § 1569.49(e). Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

The facility is closed. A copy of this report and appeal rights were provided to the Licensee.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 27-AS-20221223104058

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: 11/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/21/2023 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed... (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility is closed.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not ensure medical attention is sought timely for residents. Resident R1, R2, and R3 did not receive medical attention in a timely manner, which resulted in hospitalization and ultimately death. This 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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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