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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001903
Report Date: 10/25/2022
Date Signed: 10/25/2022 01:30:26 PM


Document Has Been Signed on 10/25/2022 01:30 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:IVY RIDGE ASSISTED LIVINGFACILITY NUMBER:
347001903
ADMINISTRATOR:REBECCA MCFADDENFACILITY TYPE:
740
ADDRESS:2030 23RD STREETTELEPHONE:
(916) 455-8849
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 29DATE:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Zoe ZhengTIME COMPLETED:
01:45 PM
NARRATIVE
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On 10/25/22 at 8:30am, Licensing Program Analysts (LPAs) Kevin Gould and Tung Truong conducted an unannounced case management inspection to address concerns with facility administration and to discuss POC documents. LPAs met with Zoe Zheng AKA: Hong Trinh, Admin certification # 6042113740 Expiration date: 12/4/22.

LPAs Gould and Tuong conducted a walk through of the facility to ensure the health and safety of residents in care. LPAs discussed the transfer of property which was corroborated as June 2022. The department had received no notification of the sale of property. LPA Gould spoke via phone call with the licensee on file who disclosed to LPA that the licensee is no longer involved in any way at the facility and they sold the property in June 2022.

As of Friday 10/21/22 the facility has not had a qualified administrator appointed to oversee the facility and approved by the department. As of today, 10/25/22 no documents have been provided to the department to approve a new administrator. LPAs advised facility representative that they may need to identify another individual to be the Administrator due to the facility representative's Administrator certificate will expire on 12/4/22 and has yet to submit required training for recertification. LPAs advised that recertification approval may take several months due to department backlog of applications.

Upon LPA's entry into the unlocked office LPAs observed prescription medications that have left unsecured in the unlocked office. LPAs reviewed medication administration logs and observed Resident's medication administration log had not been documented correctly and were missing documentation of administration on 10/24/22 and 10/25/22.

Report continued on LIC 9099-C.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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Document Has Been Signed on 10/25/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: IVY RIDGE ASSISTED LIVING
FACILITY NUMBER: 347001903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited

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Sale of licensed facility; resulting issuance of new license; procedure: The licensee shall provide written notice to the department and to each resident or his or her legal representative of the licensee's intent to sell the facility at least 30 days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is
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longer. This requirement was not met as evidenced by Licensee failed to notify the department of the sale of the property to Reliance Group Investments, LLC and the Licensee no longer has control of property which poses an immediate health,safety and personal rights risk to residents in care.
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Type A
10/26/2022
Section Cited

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Sale of licensed facility; resulting issuance of new license; procedure: Except as provided in subdivision (e), the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter. This requirement was not met as evidenced by statements obtained from
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the Licensee that they have sold the property and business and are no longer involved in operation of the facility and the facility is being fully operated by new ownership which has not submitted an application for change of ownership which poses an immediate health, safety and personal rights risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: IVY RIDGE ASSISTED LIVING
FACILITY NUMBER: 347001903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited

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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPAs review of medication administration logs for R1 which revealed facility staff administering medications failed to properly document
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medications administered to residents on 10/24/22 and 10/25/22 which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
10/26/2022
Section Cited

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Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by LPAs counducted a walkthrough of the
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 facility and observed a bag of prescription medications stored in a facility office that was not locked and accessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: IVY RIDGE ASSISTED LIVING
FACILITY NUMBER: 347001903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited

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Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to
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permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by the department confirming the former administer resigned on 10/21/22 and the facility has not submitted a new administrator for approval,
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: IVY RIDGE ASSISTED LIVING
FACILITY NUMBER: 347001903
VISIT DATE: 10/25/2022
NARRATIVE
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The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the facility representative. Appeal Rights were issued, and a copy of this report was left at the facility..
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5