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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:31:05 PM


Document Has Been Signed on 01/17/2024 03:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:STEPHANIE LIMBERGFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: DATE:
01/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Stephanie Limberg, AdministratorTIME COMPLETED:
03:45 PM
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At approximately 12:55pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report (IR) received on 01/08/2024. LPA was greeted by greeter at front desk. Stephanie Limberg, Administrator met LPA shortly after LPA arrival.

On 01/08/2024 CCL received SOC341 reporting abuse of resident (R1) by way of self-neglect. This abuse resulted in 72 hour hold and hospitalization. Admin cross reported incident to police, police report #24-271 was filed. Copy of police report not currently available.

On 1/6/2024 at approximately 9:30pm R1 jumped out their apartment window, located on the second floor of Assisted Living. Staff called 911 and notified Admin immediately. R1 was transported to Santa Rosa Memorial Hospital (SRMH) via ambulance. Admin immediately notified POA and PCP.

Per LPA interview with Admin, as of today, R1 remains at SRMH. R1 has a fractured back resulting from fall. Per R1's POA, R1 will not be returning to the community; the plan is to find an appropriate new community in which R1 can reside. As of now, a definitive move-out date for R1 has not been determined. If R1 does return to Ivy Park community, R1 will be reassessed prior to discharge from SRMH to ensure her care needs can be met by staff.

At approximately 2:00pm LPA reviewed R1's Care Plan, Charting Notes, LIC602, and Behavior intervention record.

  • Per Care Plan: resident is at high risk for falling. Fall risk to be mitigated by staff, encouraging R1 to use walker and sit on walker if feeling dizzy. R1 exhibits attention seeking behavior relating to medical attention and 911 services. R1 talks about wanting to die and expresses negative thoughts to others.
  • Per charting notes: resident often claims they aredying (not that they wantto die), resident's typical behavior fluctuates between negative attention-seeking behavior and self-isolation in their room. While self-isolating, resident displays various symptoms of depression. Resident pushes pendant very often, including when caregivers are already present and assisting her in her room. Resident often makes statement claims to staff related to medical misperceptions. On 12/25/2023 resident had an unwitnessed fall for which they were sent to the ER, hip and lumber spine normal per xray.

Continued on 809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT SANTA ROSA
FACILITY NUMBER: 496804017
VISIT DATE: 01/17/2024
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Continued from 809C...
  • Per LIC602: resident is ambulatory, has a history of depression and anxiety as well as suicidal/self-abuse, needs assistance with some ADLs, and is not able to leave facility unassisted.


Per LPA interview, Admin took immediate action to mitigate future incidents of a similar nature by fitting all windows in Assisted Living with safety restrictors that prevent windows from opening more than five [5] inches (windows in Memory Care already fitted with window safety restrictors). Also, additional staff training conducted on suicide precautions and ideation.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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