347005512-9-12-2024-27-AS-KHOS-D93UGM-20240913153434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 09/12/2024
Date Signed: 09/12/2024 09:31:32 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: 57	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michelle Swearingen		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Resident fell due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams 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, observation, and record review. LPA Moleski interviewed two residents (R1-R2), seven staff members (S1-S7), and a resident’s responsible party (R1’s RP).

LPA Moleski reviewed an incident report on 5/1/24 regarding the discovery of an injury on a resident (R1) on 3/30/24. The incident report stated that three staff members (S3-S5) who were working the night shift between 3/29/24 and 3/30/24 had observed a lump with bruising on R1’s back during a change of R1’s briefs. R1 was sent out to the hospital, according to the incident report. According to R1’s medical records, R1 was diagnosed with a spinal fracture at the hospital. [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: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: 09/12/2024

NARRATIVE

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LPA Moleski reviewed shift change notes regarding R1 dated between 3/26/24 and 3/29/24. A note made on the night of 3/29/24 stated that R1 refused to be changed for most of the night, but around 5 a.m., staff observed the bump and bruise on R1. The preceding notes do not make any indication of any observed injuries or falls suffered by R1.

LPA Moleski reviewed R1’s file and did not observe any prior incident reports regarding falls suffered by R1 while at the facility. LPA Moleski reviewed R1’s preadmission appraisal, dated 11/20/23, which states that R1 did not need help in transferring in and out of bed. The appraisal was signed by R1’s RP. The appraisal states that R1 was active, but had difficulty climbing or descending stairs. Both R1’s appraisal and R1’s LIC 602, dated 11/20/23, indicated that R1 was fully ambulatory.

In an interview, R2, R1’s spouse and a resident of this same facility, said that R1 fell three times while they were still living together, before they moved into the facility. In an interview, R1 said they could not recall what had happened on the night of 3/29/24 or the morning of 3/30/24. R1 was diagnosed with dementia, according to their LIC 602.

In an interview, S4, said that R1 did not appear to be in pain on the night of 3/29/24 and the morning of 3/30/24. S4 said that R1 stayed up most of the night, calmly sitting in a chair in their room. S4 said that R1 had refused to be changed by the night shift staff until approximately 4:30 or 5 a.m. on 3/30/24, at which point R1’s injuries were discovered. In an interview, S5 said that from the start of their shift, R1 was in their room sitting in their chair. S5 said that R1 remained in their chair until both himself and S4 changed R1 in the early morning. S5 said R1 did not express pain at any point during the shift. S4 and S5 said that R1 is able to get up from the chair independently. S4 said R1 has fallen previously.

LPA Moleski interviewed the two caregivers assigned to R1’s cottage during the afternoon shift on 3/29/24. In an interview, S6 said that R1 was in their chair during the afternoon shift, and did not want to get up, so S6 was not able to change R1, and therefore did not observe any injuries on R1. S6 said that R1 has fallen in the past, but is able to get up on their own. S6 said that, during crossover, the other caregiver on the afternoon shift, S7, said they had changed R1. [continued on 9099-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 09/12/2024

NARRATIVE

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In a phone interview, S7 said that they had changed R1 during the shift with their coworker, but had not observed any injuries on R1. LPA Moleski attempted to acquire additional information from S7, but the call was terminated. LPA Moleski called S7 again on 5/29/24, 5/31/24, and 6/14/24, and left voicemail messages each time. LPA Moleski also sent a text message asking to continue their conversation, to which he received no response.

LPA Moleski was informed by Swearingen that S7 was terminated as of 8/12/24, in part due to attendance issues. LPA Moleski reviewed a disciplinary action notice regarding S7, dated 8/10/24. The notice stated that S7 was working a night shift on 8/5/24 and was present while a resident was out of bed and sitting on a bench in the common area of their cottage, but did not assist them back to their room.

The department has determined the following as it relates to the allegation that a resident fell due to lack of supervision.

Based on interviews, observation, and record review, 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 the above 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: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

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