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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 02:21:06 PM


Document Has Been Signed on 10/19/2022 02:21 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 - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rebecca McfaddenTIME COMPLETED:
02:30 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 concerns regrading a resident's elopement on 10/17/22. LPA Gould met with Administrator, Rebecca McFadden and together discussed the reported incident. LPA reviewed incident report for R1 and reviewed R1's LIC 602 (Physician's Report).

Based on the incident report and review of resident's LIC 602, the resident has been determined to be unable to leave the facility unassisted by his physician. Staff members present did not observe resident depart the facility and later reported resident missing to local law enforcement. Resident was located by law enforcement and staff returned the resident to the facility.

Based on the information obtained at the time of inspection the following deficiency is 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 02:21 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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Care of Persons with Dementia: Without violating Section 87468, Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility. This requirement was not met as evidenced by Resident with dementia and was identified as unable to leave the facility unassisted, eloped from the facility without staff knowledge
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which poses an immediate heath, 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)
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