496804017-12-16-2022-21-AS-KMOA-CMCQFC-20221222110742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804017
Report Date: 12/16/2022
Date Signed: 12/16/2022 03:01:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220816152630

FACILITY NAME:	IVY PARK AT SANTA ROSA		FACILITY NUMBER:	496804017
ADMINISTRATOR:	LYDIA GRAVELYN		FACILITY TYPE:	740
ADDRESS:	4225 WAYVERN DRIVE		TELEPHONE:	(707) 538-2590
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	114	CENSUS: 79	DATE:	12/16/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Health Services Director, Teresa Weerts		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision causing resident to sustain an unstageable pressure injury
Staff did not address a change in the resident's health condition
Facility failed to report death, fall, and pressure injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/16/2022 to deliver complaint findings regarding the allegations above. LPA met with Health Services Director Teresa Weerts.

There was an allegation that facility failed to report death, fall, and pressure injury. During the initial complaint inspection on 08/18/2022 LPA obtained copy of Resident 1’s (R1) file. LPA contacted R1’s responsible party (RP) for statement concerning the allegations. RP indicated that a fall had occurred but that it had been reported to them by the facility. Record review revealed a move in date of 06/23/2022 and a move out date of 07/05/2022. R1 passed away after moving out of the facility. LPA obtained copies of hospice records. Hospice records noted skin abrasions on 07/03/2022 but no other wounds. Hospice care plan did not have measures in place to address the presence of a significant wound. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.
Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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 21-AS-20220816152630

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: IVY PARK AT SANTA ROSA	FACILITY NUMBER: 496804017
	VISIT DATE: 12/16/2022

NARRATIVE

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There was an allegation that staff did not address resident’s change in condition. Record review revealed an admission date of 06/23/2022. Care notes indicate that resident was sent out on 06/24/2022 for a change of condition and that family was notified. Per interview with Health Services Director, R1 steadily declined while in care which resulted in hospice admission on 07/02/2022. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There was an allegation that neglect/lack of care and supervision resulted in resident sustaining an unstageable pressure injury. R1 was sent to hospital on 06/24/2022 for change of condition. Hospital performed skin assessment and noted no pressure injuries. Skin assessment performed by hospice on 07/03/2022 indicated skin abrasion on coccyx but not an unstageable pressure injury. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

No deficiencies cited during today's inspection.

Exit interview conducted with Teresa Weerts and a copy of this report emailed to the facility.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC9099 (FAS) - (06/04)

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