347005512-5-1-2024-27-AS-KHOS-D93UGN-20240913153435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:02:46 AM

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
04/04/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240404121416

FACILITY NAME:	IVY PARK AT LAGUNA CREEK		FACILITY NUMBER:	347005512
ADMINISTRATOR:	MICHELLE SWEARINGEN		FACILITY TYPE:	740
ADDRESS:	6727 LAGUNA PARK DR		TELEPHONE:	(916) 683-1881
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	108	CENSUS: 56	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michelle Swearingen		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not notify resident's responsible party of incident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this allegation. 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.

During interviews, two staff members (S1-S2) said that R1's responsible party (RP) was notified by phone shortly after R1's injury was discovered. During an interview, R1's RP said they had been contacted by phone on the morning the injuries were discovered.

[continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240404121416

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: 05/01/2024

NARRATIVE

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The department has determined the following as it relates to the allegation that staff did not notify a resident's responsible party of incident:

Based on interviews, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Swearingen.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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