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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001903
Report Date: 10/19/2022
Date Signed: 10/19/2022 02:23:47 PM


Document Has Been Signed on 10/19/2022 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
347001903
ADMINISTRATOR:REBECCA MCFADDENFACILITY TYPE:
740
ADDRESS:2030 23RD STREETTELEPHONE:
(916) 455-8849
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 27DATE:
10/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rebecca McFaddenTIME COMPLETED:
02:45 PM
NARRATIVE
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On 10/19/22 at 9:00am, Licensing Program Analyst (LPA) Kevin Gould Conducted an unannounced Case Management inspection to address deficiencies observed during an unrelated Case Management Inspection. LPA Gould met with Administrator, Rebecca McFadden and together conducted a walk through of the facility.

LPA conducted file reviews for several residents and observed the facility was not following physician's instructions regarding blood glucose testing for one resident. Per the physician's instructions, blood glucose testing should be conducted four (4) times daily and LPA only observed testing three (3) times daily and no recorded readings for 10/2/22, 10/3/22, 10/9/22 and 10/10/22.

LPA also observed the upstairs bathroom with excess water on the floor that was pooling on the floor and poses a hazard to residents in care. LPA observed the bedroom and residents in room number 12 and observed a large number of flies in the room and crawling over the legs of the bedridden resident.

based on observations by LPA Gould the facility does not have enough staff present to meet the needs of residents and conduct routine housekeeping and medication administration in a manner that meets the resident's needs. Prior to this inspection, a resident was able to elope from the facility unassisted due to staff attending to other duties and not ensuring residents who have been unable to leave the facility unassisted are monitored and redirected prior to leaving the facility.

The following deficiencies are cited per California Code of Regulations, TITLE 22. An exit interview was conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2022 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited

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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPAs review of resident records, LPA observed missing blood glucose monitoring (BGM) records and observed
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the facility was not following physician's instructions of (BGM) four (4) times a day. LPA only observed BGM recorded three (3) times a day which poses an immedate health, safety and presonal rights risk to residents in care.
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Type A
10/20/2022
Section Cited

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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by LPA's observations of standing water
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pooling on the floor of the upstairs bathroom utilized by residents. LPA also observed in room number 12 a large number of flies present and crawling over bedridden resident's legs which poses an immediate health, safety and personal rights risk to residents 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: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/19/2022 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited

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Resident’s Bill of Rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by LPAs observations of facility operation including inability of staff to complete all physician directions as ordered
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by the physician including blood glucose monitoring and to provide a clean and safe living environment including presences of insects and pests in the facility and on residents and standing water in the bathroom. LPA observed that staff are not currently meeting the needs of residents which poses an immediate health, safety and personal rights risk to residents 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: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3