347001903-11-3-2022-27-AS-TTRG-CKTPGD-20221103111810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001903
Report Date: 10/26/2022
Date Signed: 11/03/2022 11:18:20 AM

Document Has Been Signed on 11/03/2022 11:18 AM - 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 LIVING		FACILITY NUMBER:	347001903
ADMINISTRATOR:	REBECCA MCFADDEN		FACILITY TYPE:	740
ADDRESS:	2030 23RD STREET		TELEPHONE:	(916) 455-8849
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95818
CAPACITY:	36	CENSUS: 29	DATE:	10/26/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Pak Wu and Hong Trinh		TIME COMPLETED:	10:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An office meeting was conducted today in the Sacramento Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to discuss the high volume of deficiencies/complaints/inability to remain in substantial compliance with the regulations/or specific incidents that has occurred within the last 12 months. Present in the meeting is Regional Manager Stephenie Doub, Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst Tung Truong, Licensing Program Analyst Kevin Gould and Ivy Ridge Assisted Living, management company Hong Trinh aka Zoe Zheng and Pak Wu. Michelle and Dwayne Hardy of Heterielle Inc., co licensee, was not present during this meeting. The informal conference process was explained during this meeting. Issues discussed during the meeting were: - The licensee has abandoned the facility - Lease back agreement with licensee, Heterielle Inc. - Change of Ownership (CHOW) application - Care and Supervision (AWOL) - Eviction procedures - Administrator Certificate and Qualifications *The facility has stated they will do the following to achieve continued and substantial compliance:* Report continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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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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
	VISIT DATE: 10/26/2022

NARRATIVE

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- Provide the following to LPA by Friday 10/28/2022:
1. Lease back agreement
2. A statement in writing from the licensee, Heterielle Inc. that they are still involved with the facility and understand their responsibility until a license is approved for the Change of Ownership.
- Ensure eviction procedures are followed as required by Title 22 Regulation.
- Provide training to staff on AWOL
- Ensure adequate staff are present to provide care and supervision to residents in care at - the facility.

During this meeting Hong Trinh and Pak Wu confirmed that they understood the facility was only approved for adding a management company (Ivy Ridge Care, Inc.) and that a change of ownership application will need to be approved by the Department.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with all mentioned representatives via Microsoft Teams and a copy of this report will be provided to the facility via email. A copy must be signed and returned to Community Care Licensing (CCL) and the one copy is to be retained by the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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