347001903-4-29-2022-27-AS-KHOS-CEAJ8X-20220510065015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001903
Report Date: 04/29/2022
Date Signed: 04/29/2022 02:20:19 PM

Unsubstantiated

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
01/14/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20220114134615

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: 13	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rebecca McFadden, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Licensee is not releasing resident's property.

INVESTIGATION FINDINGS:

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On 4/29/2022 at 1:30 PM, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to deliver the complaint findings. LPA met with Administrator Rebecca McFadden and explained the purpose of today's visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. It was alleged that resident sustained unexplained injuries while in care. Based on interviews and a review of the documents gathered during the course of this investigation, it was learned that resident 1 (R1) had an unwitnessed fall on 11/21/2021 and was sent to ER. Staff 1 (S1) who found R1 on the floor observed that R1’s face looks puffy. S1 stated R1 has no injuries. R1 was transferred to Mercy General to be evaluated. Hospital discharge summary revealed that R1 has no injuries upon arrival to Mercy General Hospital.

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: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220114134615

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: 04/29/2022

NARRATIVE

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The complaint also alleged that the Licensee is not releasing resident’s property. Based on interviews and review of records, it was learned that the facility has attempted to contact R1’s family multiple times to arrange pick up of R1’s belongings; however, the phone messages were full and not taking new messages. It was learned that R1's family refused to be vaccinated or have a negative COVID test in order to enter the facility. It was learned that R1’s personal belonging was picked up on 3/24/2022 by R1's nephew.

As a result of this investigation, this Department found the allegations 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.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. Exit interview held, a 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: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

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