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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:01:43 AM


Document Has Been Signed on 05/01/2024 10:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:IVY PARK AT LAGUNA CREEKFACILITY NUMBER:
347005512
ADMINISTRATOR:MICHELLE SWEARINGENFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 56DATE:
05/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michelle SwearingenTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit.

LPA Moleski opened a complaint investigation at this facility on 4/11/24. During the complaint investigation, it was revealed that a resident (R1) suffered a suspected unwitnessed fall on the morning of 3/30/24, and was sent to the hospital with an injury.

LPA Moleski reviewed CCLD records and observed that no incident reports were received regarding this incident. LPA Moleski asked a staff member (S1) for a fax transmittal sheet from the incident report. S1 informed LPA Moleski that no transmittal sheet was available. S1 provided LPA Moleski with a printout of an incident report on 4/11/24, which described R1's injury and hospital visit. The incident report did not indicate that CCLD or any other agencies were notified of the incident.

This facility is being cited per 22 CCR Section 87211(a)(1)(B). An exit interview was held with Swearingen. Appeal rights and a copy of this report were left with Swearingen.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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Document Has Been Signed on 05/01/2024 10:01 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: IVY PARK AT LAGUNA CREEK
FACILITY NUMBER: 347005512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
87211(a)(1)(B)

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"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: ... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision."
This requirement was not met as evidenced by:
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Licensee agrees to write a signed statement acknowledging the requirement to submit incident reports to CCLD in a timely manner. Licensee agrees to submit this statement to LPA Moleski by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interivews, LPA Moleski did not receive an incident report regarding a resident injury and hospital visit within seven days of the occurrence, which poses a potential health, safety, and/or personal rights risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
LIC809 (FAS) - (06/04)
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