347005512-9-3-2025-27-AS-SRIN-DLN2LB-20250918172917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 09/03/2025
Date Signed: 09/03/2025 03:22:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2025 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250617103041

FACILITY NAME:	IVY PARK AT LAGUNA CREEK		FACILITY NUMBER:	347005512
ADMINISTRATOR:	JAMES DIAL		FACILITY TYPE:	740
ADDRESS:	6727 LAGUNA PARK DR		TELEPHONE:	(916) 683-1881
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	108	CENSUS: 85	DATE:	09/03/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	James Dial		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal eviction
Medications were not provided to resident as needed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit.

This investigation consisted of interviews and record review. LPA Moleski interviewed three facility staff members (Dial, S1, S2), a former resident of this facility (R1) and that resident's responsible party (R1's RP). LPA Moleski reviewed R1's file, including all medication administration records (MARs) and medication orders.

R1 moved into this facility on June 2, 2025, and moved out on June 13, 2025. Based on interviews with staff and with R1's RP, there was no written notice regarding R1's move-out, and all conversations regarding the move-out were verbal. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 27-AS-20250617103041

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 09/03/2025

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
26
27
28
29
30
31
32

Based on interviews with staff, R1 wandered from their delayed-egress cottage on at least one occasion, and frequently attempted to elope after that. Charting notes regarding R1 indicate that on 6/3/25, R1 wandered "on to the streets," with staff following to supervise R1. After this and other incidents, Dial said R1's RP was "required" to acquire third-party one-on-one caregivers to supervise R1 during certain hours. This issue will be addressed in a separate case management report.

In an interview, Dial said that R1 was not a good fit for the facility due to the open cottage-style layout, and R1 would be better served by a more secure facility. Dial said he did explain this to R1's RP, but he never told R1's RP that R1 needed to leave.

In an interview, R1's RP did not describe R1's move-out as an eviction, and R1's RP complimented facility staff. R1's RP said that Dial did explain that R1 was "not a good fit" at this facility. R1's RP said they asked Dial what their options were, and Dial gave a preferred timeline for move-out, however this was described by R1's RP as Dial's preference, and not a requirement.

In an interview, R1's RP did raise concerns regarding two of R1's medications, a certain depressant and a certain antipsychotic. LPA Moleski reviewed R1's medication list from their previous skilled nursing placement, dated 6/2/25, and a medication clarification signed by R1's physician dated 5/31/25. LPA Moleski observed on each an order for R1 to take the antipsychotic twice daily and an order for R1 to take the depressant as needed every six hours. No additional orders for either medication were included in these records.

LPA Moleski reviewed R1's MARs and observed that these orders were listed as described. LPA Moleski further observed that these medications were administered as ordered during the duration of R1's stay at this facility. The department has determined the following as it relates to the allegations that a resident was illegally evicted and that medications were not provided to resident as needed: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Dial.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2