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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:49:42 PM

Substantiated


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
02/27/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240227090631
FACILITY NAME:IVY PARK AT LAGUNA CREEKFACILITY NUMBER:
347005512
ADMINISTRATOR:MORGAN WHINERYFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 55DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michelle SwearingenTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not provide sufficient notice of rate increase
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit.

This investigation consisted of interviews and record review. LPA Moleski interviewed a former resident’s responsible party (R1’s RP). R1’s RP said that they had not received any sort of written notification after a reassessment for R1 raised R1’s care costs. R1’s RP said they were only made aware of the increase in costs by looking through their bank statements.

LPA Moleski reviewed a reassessment for R1 dated 12/11/23. The assessment was unsigned by either facility representatives or by R1’s RP. LPA Moleski asked Swearingen for any written notifications sent to R1’s RP regarding increased costs due to an increased level of care. Swearingen was unable to produce any such notifications. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 6
Control Number 27-AS-20240227090631
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: 05/30/2024
NARRATIVE
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 A staff member (S4) claimed to have conducted a second reassessment on January 1, 2024 with R1’s RP present. LPA Moleski asked Swearingen for a copy of this second reassessment and written notifications sent regarding any increased care costs. Swearingen was unable to provide any such documentation in response to this request. Swearingen reached out multiple times requesting documentation from the prior management company in order to respond to LPA Moleski’s requests, but did not receive documentation to provide to LPA Moleski as described above.

The department has determined the following as it relates to the allegation that staff did not provide sufficient notice of rate increase:

Based on interviews and record review, sufficient written notice was not provided to R1’s RP after care costs were increased. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per HSC Section 1569.657(a). An exit interview was held with Swearingen. A copy of this report and appeal rights were left with Swearingen.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/27/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240227090631

FACILITY NAME:IVY PARK AT LAGUNA CREEKFACILITY NUMBER:
347005512
ADMINISTRATOR:MORGAN WHINERYFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 55DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michelle SwearingenTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff force fed resident
Staff did not inform resident's authorized person of change in condition
Staff did not meet resident's needs
Staff did not refund fees according to resident's Admission Agreement
Staff did not answer the facility telephone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit.

This investigation consisted of interviews and record review. LPA Moleski interviewed a former resident’s responsible party (R1’s RP) and 13 staff members (S1-S13).

R1’s RP claimed in late February 2024 that they were owed nearly $3,000 in refunds. LPA Moleski reviewed a reassessment for R1 dated 12/11/23 which increased R1’s level of care and therefore raised care costs. LPA Moleski reviewed email communications between R1’s RP and staff of this facility in which R1’s RP disputed the increased costs. LPA Moleski reviewed R1’s billing records. LPA Moleski observed that these increased costs, totaling $2,905.45, were refunded to R1’s RP. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240227090631
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: 05/30/2024
NARRATIVE
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The refunds were processed effective 2/12/24. LPA Moleski reviewed a statement from February 2024 indicating that credits were provided for resident care and for room and board costs for the month of January. In an interview, R1’s RP said that they had received the refunds.

LPA Moleski reviewed an incident report regarding R1’s hospital visit on 12/7/23. The report stated that R1’s RP called a staff member to check on R1. The staff member said that R1 was pocketing food and refusing meals. R1’s RP said R1 should be taken to the emergency room. R1’s RP picked up R1 around 1 p.m. and took R1 to the hospital. R1 was diagnosed with failure to thrive and was sent back on 12/12/23 with palliative care. In an interview, R1’s RP was aware of R1’s hospitalization and said they had visited R1 while hospitalized.

In an interview, R1’s RP said that staff were “force feeding” R1. When asked for clarification, R1’s RP said that staff continued to ask R1 if R1 wanted to eat, although R1 did not want to eat. LPA Moleski reviewed R1’s daily notes and observed in the record a pattern of limited food intake and many refusals of food and drink. Refusals are documented in the notes, and the authors of the notes indicated on several occasions the exact amounts of food which R1 did accept. None of the staff members interviewed had witnessed staff members force feeding R1 or any other residents, although several did remark that R1 often refused meals and/or ate very little food. Among the staff members interviewed, one staff member (S5) said that on one occasion, S5 came in for their shift and observed that R1 had not been changed by the previous shift. None of the other staff members interviewed had witnessed neglect or lack of care for the resident. Three other staff members (S5, S7, S9) who worked directly with R1 said that R1’s continence needs were met and had not witnessed any instances were R1 had been waiting for care or needing to be changed.
Of the staff members interviewed, two (S5, S9) said there were temporarily previous issues with phone calls being transferred from the main line to the appropriate cottage. None of the other staff members interviews reported any issues with the phone systems. LPA Moleski has not had issues reaching someone at the facility by phone.

[continued on 9099-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240227090631
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: 05/30/2024
NARRATIVE
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The department has determined the following as it relates to the allegations that staff force fed a resident, that staff did not inform a resident’s authorized person of a change in condition, that staff did not meet a resident’s needs, that staff did not refund fees according to the resident’s admission agreement, and that staff did not answer the facility telephone.

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 Swearingen.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240227090631
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2024
Section Cited
HSC
1569.657(a)
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“(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.” This requirement was not met as evidenced by:
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Licensee agrees to write a statement acknowledgement of the requirements and that they will be adhered to in the future. vincent.moleski@dss.ca.gov
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Based on interview and record review, no notification was provided to R1’s RP after rates were raised due to an increase in level of care, 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: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
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