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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 10/16/2025
Date Signed: 10/16/2025 03:53:43 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
10/14/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251014081930
FACILITY NAME:IVY PARK AT LAGUNA CREEKFACILITY NUMBER:
347005512
ADMINISTRATOR:JAMES DIALFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 86DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karan BassiTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not allow resident access to bedroom
Staff do not safeguard residents' confidential information
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open this complaint investigation. LPA Moleski met with administrator Karan Bassi and explained the purpose of the visit.

This investigation consisted of record review, interviews, and observation.

In an interview, Bassi said that a resident (R1) was moved out of their room in Dogwood Cottage, D3, in the facility's memory care area, on September 25 to a room in Cedar Cottage, C2, in the facility's assisted living area. The facility's memory care director (S1) said that they had been instructed to identify two memory care residents who may be appropriate to move into assisted living due to new prospective residents seeking memory care placements. R1 was one of these residents, and R2 was another. Both Bassi and S1 said that R1's responsible party asked to return R1 to memory care after a short period of time. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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-20251014081930
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: 10/16/2025
NARRATIVE
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Bassi said that R1 was moved back to memory care on October 1, but R1 could not return to their original room, D3, because another prospective client had already placed a deposit on the room. R1 was moved to room D7, according to Bassi.

LPA Moleski spoke with R1's responsible party over the phone, who declined to answer questions. In an interview, R1 said they had been recently moved, but that they preferred their original room to their new room and and that they did not know why they were moved.

LPA Moleski reviewed R1's and R2's files. LPA Moleski observed that R1 had only one admission agreement on file, dated April 30, 2024. The admission agreement specifies R1's room as room D3. The admission agreement states, in part, that "[R1] may live in [their] room on a month-to-month basis..." The admission agreement does include sections which clarify expectations in the event of room transfers, as well as termination conditions. Page 7 of R1's admission agreement states that "Ivy Park may need to substitute your apartment with another apartment ... for any ... reasonable purpose, as determined by the executive director of the community ... upon a thirty (30) day notice. A request by you for an apartment substitution will be granted in Ivy Park manager's discretion." 22 CCR Section 87507(c-d) requires all attachments or modifications made to admission agreements to be signed and dated. LPA Moleski requested all modifications to R1's admission agreement. Bassi provided LPA Moleski an apartment transfer form for R1, indicating that R1 was moved from room C2 to D7 as of October 1. The form was not signed by facility representatives, the resident, or the resident's responsible party. Page 8 of R1's admission agreement indicates that their contract may be terminated by the resident "at any time, with or without cause, by giving the executive director of the community ... thirty (30) days prior written notice of termination." Licensee-initiated termination of contract is outlined by 22 CCR Section 87224, which requires under most circumstances a 30-day notice. The termination conditions outlined in the admission agreement do not indicate that, by moving into a different room, R1's contract was automatically terminated. R1 was not required to have a new admission agreement signed for their stay in room C2 between Sept. 25 and Oct. 1. 22 CCR Section 87507(c) requires a new admission agreement seven days after admission, and R1 was in room C2 for only six days, according to Bassi. However, in lieu of any signed and dated modifications, formal termination with applicable written notice, or an entirely new signed and dated admission agreement for their new room, R1's contract remained in effect as originally agreed upon, meaning that R1 should have retained the right to return their original room, D3. [continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
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Control Number 27-AS-20251014081930
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: 10/16/2025
NARRATIVE
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LPA Moleski reviewed the file of the resident who currently resides in room D3 (R3). LPA Moleski observed a signed admission agreement permitting R3 to live in room D3. The admission agreement was dated September 27, just two days after R1 left room D3. LPA Moleski reviewed a payment authorization form and a community fee receipt for R3, both signed and dated Sept. 27.

LPA Moleski did not observe a current admission agreement for R1 for their new room, D7. According to Bassi and S1, R2 was moved out of room D7 into room C2, in order to permit R1 to return to their initial memory care cottage. LPA Moleski reviewed R2's file and observed no admission agreements on file. Bassi said R2's initial admission agreement was written under the previous management company. LPA Moleski was provided two apartment transfer forms for R2. One indicated that R2 was to be moved from room D7 to room C2, however, this form was not signed. The second indicated that R2 was to be moved from room D7 to room C5. This version was signed by R2's responsible party, and by a facility representative, and was dated Sept. 26. However, as of today's visit, R2 is living in room C2, not room C5, as the signed and dated modification states. R2 had no current signed and dated admission agreement on file regarding their present residency in room C2.

During a tour of Cedar cottage, LPAs Moleski and Lindstrom observed an office area in the cottage unattended. LPAs Moleski and Lindstrom observed several binders left lying on a desk area, despite the presence of locking cabinets directly above the desk. LPAs Moleski and Lindstrom observed multiple documents containing confidential resident information present in these binders, including residents' diagnoses, care plans, care notes, prescription information, medical information, and other personal identifying information. There was not a staff member in the immediate vicinity when LPAs Moleski and Lindstrom began inspecting the area. LPAs Moleski and Lindstrom did, however, observe residents and at least one visitor walking by during their inspection of the records.

The department has determined the following as it relates to the allegations that staff did not allow a resident access to their bedroom and that staff do not safeguard residents' confidential information:

Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87507(f) and 87506(c)(1) An exit interview was held with Bassi. A copy of this report and appeal rights were left with Bassi.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
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Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20251014081930
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: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
10/24/2025
Section Cited
CCR
87507(f)
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"(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with updated admissions documents for R1 and R2 by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interview, all terms and conditions of residents' admission agreements and/or modifications were not adhered to, which poses a potential health, safety, and/or personal rights risk.
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Under Appeal
Type B
10/24/2025
Section Cited
CCR
87506(c)(1)
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"(c) All information and records obtained from or regarding residents shall be confidential ... (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents..." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with inservice training records regarding safeguarding confidential records by POC due date.
vincent.moleski@dss.ca.gov
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Based on observation, confidential resident records were not stored or safeguarded in a manner which protected their confidentiality, 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
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