<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 07/08/2025
Date Signed: 07/08/2025 04:24:43 PM

Document Has Been Signed on 07/08/2025 04:24 PM - 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/
DIRECTOR:		JAMES DIALFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 108CENSUS: 82DATE:
07/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:James DialTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit.

LPA Moleski reviewed an internal incident report which was provided by facility staff on 06/20/25 during a complaint investigation visit. The internal incident report described a resident (R1) engaged in "hazardous wandering" on 6/3/25. According to the internal incident report, R1 was supervised, but had left the community. Dial said R1 was walking along the sidewalk with staff, and 911 was called as a result because R1 was not redirectable. R1 has a diagnosis of dementia and suffers from confusion and wandering behaviors, according to R1's LIC 602, which is dated 5/31/25.

LPA Moleski reviewed CCLD fax and email records and observed no incident report was received regarding this incident. The facility's resident care coordinator (S1) said an incident report was not submitted to CCLD regarding this incident. Dial agreed that an incident report should have been submitted regarding this incident.

Dial said there was a second incident on 6/7/25 wherein R1 left their cottage, but did not leave the facility grounds. LPA Moleski asked Dial to provide the internal incident report from this second incident when possible. Dial agreed to do so.

This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.
Stephen RichardsonTELEPHONE: (916) 263-4746
Vincent MoleskiTELEPHONE: (559) 365-5294
DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
Document Has Been Signed on 07/08/2025 04:24 PM - It Cannot Be Edited


Created By: Vincent Moleski On 07/08/2025 at 04:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2025
Section Cited

1
2
3
4
5
6
7
"(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below ... Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interview and record review, an incident which threatened R1's health, safety, and/or welfare was not reported to CCLD, which poses a potential health, safety and/or personal rights risk.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 263-4746
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (559) 365-5294
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3