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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005180
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:17:32 PM


Document Has Been Signed on 05/03/2024 02:17 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:IVY PARK AT SACRAMENTOFACILITY NUMBER:
347005180
ADMINISTRATOR:SARA WEININGERFACILITY TYPE:
740
ADDRESS:345 MUNROE STTELEPHONE:
(916) 486-0200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:70CENSUS: 56DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:SARA WEININGERTIME COMPLETED:
02:15 PM
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On 05/03/24, Licensing Program Analyst, Kimberly Viarella, made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Sara Weininger and a brief interview followed.

DFA Certificate Number: 7008349740 and expires on 03/26/26

Upon entering the facility, the LPA observed breakfast being served in the Assisted Living Dining Room. LPA observed 15 residents eating their morning meal. LPA continued on into the kitchen, which was inaccessible to residents in care. LPA observed an adequate food supply for 7 day non-perishable and 2 day perishable. All food items in the refrigerator were stored and dated appropriately. LPA checked the dates printed on a sample of items from the refrigerator and pantry and found that none had expired. LPA observed that no food was stored on the floor in any part of the kitchen and at the present time, all items were labeled appropriately
The fire extinguisher was last inspected on 11/16/23 by Johnson Controls.
Hot water was measured in a rest room off the dining area and was found to be 114 degrees Fahrenheit and in compliance.

LPA observed the following signage: Facility License, Resident Rights, the Emergency Preparedness Disaster Plan, See Something Say Something poster, and Ombudsman poster were all posted by entrances to the facility.

LPA then toured Memory Care (MC) with the DFA. MC was free from odor and had all of the furniture, furnishings and light to accommodate the residents in care. LPA observed 4 Care staff and 1 MedTech. LPA observed 4 residents watching television, 5 in the dining area, and 2 in the activities room coloring. LPA
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: IVY PARK AT SACRAMENTO
FACILITY NUMBER: 347005180
VISIT DATE: 05/03/2024
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inspected 2 resident rooms. Each had the required furnishings and was free of any toxic chemicals. Each bathroom had the required soap, grab bars, and bath mats and/or non-slip surfaces in the shower units.
Private bathrooms did not contain paper towels as they were able to use fabric towels. Hygiene items were kept in a locked cabinet for resident use with supervision if LIC 602 stated there was a risk for the resident to have access. LPA observed that at the time of this inspection, the individual doors to resident rooms were locked when the resident was in common areas.

LPA and DFA toured the bistro area in MC and LPA observed that all sharps were locked and inaccessible to residents in care. The Medication Room was adjacent to the Dining Room. LPA inspected medication cart and refrigerated narcotics. LPA observed bulk of medications present at this visit were bubble packs.

LPA and DFA then moved on to the Assisted Living portion of the facility. LPA inspected 2 resident rooms, they had the required furniture, furnishings, and lighting to be in compliance at the present time. They also had the required soap, grab bars, and bath mats and/or non-slip surfaces in the shower units.

LPA met with the nurse on duty in the Medication Room and medication administration and dosing were reviewed. LPA reviewed the Centrally Stored Medication Log of 2 residents in care.

Care staff response time was tested by the LPA. A resident pendant was activated upon LPA request. Care staff responded in 3 minutes and 30 seconds.

LPA conducted a record review of 3 staff and 2 resident files. All were in compliance at the present time. LPA observed residents waived the right to inventory their belongings upon admission.

LPA and DFA conducted a tour of the exterior of the building. LPA observed there were no bodies of water present and no outbuildings. LPA observed 1 window screen had a small tear. DFA said she would have it replaced right away. All other screens were free of holes at the present time and the gutters were clear of debris. There were shaded areas with furniture for residents and visitors to enjoy.

According to California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided. Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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