Ivy At Blue Oaks, The

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility has insufficient staff to meet resident care needs. Facility staff did not meet resident incontinence care needs.

On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Executive Director/ Administrator to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Title 22 personnell regulations require that staff be trained, competent and sufficent in number to meet the identified care needs of residents. One of the measures of sufficient staff numbers is in personnell records documentation of staff who actually worked per shift. This investigation was specifically reviewing staffing and care prior to January 1, 2026. Based on review of staff schedules provided the following was found: Staffing for the month of Nov. 2025: 5- AM shifts with 2 caregivers/ 1 med tech; 5- days with 3 caregivers/ 1 med tech AM; 17- days with 4 or more caregivers/ 1 med tech AM; 1- day with 3 caregivers/ 1 Med tech PM; 29- days with 4 or> caregivers/ 1 med tech PM; 2-the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 59-AS-20251226110029

Allegation investigated: Facility staff do not practice safe food handling

On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with the Executive Director/ Administrator. LPA conducted records review, site visits and interviews. LPA is unable to find and or meet the preponderance, per policy. In the three visits conducted during the course of this investigation, LPA did not observe violations of food servive regulations. Facility staff and management presented facility policy training and quality assurance measures in place that meet or exceed Title 22 regulations. Resident interviews found general satisfaction with food quality and service and occasional reports of quality from particular servers but no specific regulation violation that could be verified by this investigation. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegationthe state’s words, verbatim · CDSS document, Apr 15, 2026 · control 59-AS-20260109161127

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff threaten resident in care.

On 12/22/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit and delivered the findings for the above allegations and met with the Administrator. LPA conducted extensive interviews. LPA is unable to find and or meet the preponderance, per policy. LPA interviewed R1, Administrator, S1 and S2. R1 stated to LPA that no staff have spoken to them in a threatening way. S1, who was a staff present at the alleged incident, denied S2 stated to R1 that S3 would harm R1. S2 stated that they had told R1 S3 could assist them if R1 wanted a different caregiver, and S2 denied threatening R1. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 23, 2025 · control 59-AS-20251216113536

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not respond to resident call for assistance due to insufficient staffing. Facility staff did not provide identified care assistance to resident.

On 11/18/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Executive Director/ Administrator to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Records and statements by resident and staff found that on 8/28/25, R1 had an apparent medical emergency. Call button records for R1’s room recorded showed, on 8/28/25, bathroom pull station at 10:51, pendant alarm 11:00, bathroom pull station alarm cleared 11:05 and Pendant alarm cleared at 11:31. Bathroom pull station alarm cleared at 14 min 37 secs, pendant cleared at 30 min 25 secs. Staff working at that time were interviewed. Staff reported that a single caregiver was assigned to assisted living working with a single med tech. A second caregiver was scheduled but did not work. report continued... Substantiatedthe state’s words, verbatim · CDSS document, Nov 18, 2025 · control 59-AS-20250919152445

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not allow resident to attend activities of choice.

On 9/23/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Executive Director (ED), Michelle Swearingen, to deliver complaint findings for the above allegation. LPA reviewed resident records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Documents and interviews found that R1 moved into the facility, with their spouse, into assisted living. At the time of the admission, R1 was known to have a cognitive disorder diagnosis with behavioral disturbance. In February, R1, spouse was hospitalized. While spouse, who is the power of attorney for R1, was hospitalized, a decision was made with Administrator and another family member, to move R1 to memory care for safety and supervision of R1. Upon R1’s spouse return to the facility, R1 and spouse wished to interact within the facility and on outings. Report continued Substantiatedthe state’s words, verbatim · CDSS document, Sep 23, 2025 · control 59-AS-20250716160452

Allegation investigated: Licensee does not ensure that there are enough staff to meet resident's hygiene needs while in care. Staff member handled resident in care in a rough manner. Staff member yelled at resident in care. Licensee does not ensure that staff are adequately trained.

On 8/21/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Executive Director. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. LPA interviewed a family member of resident alleged to not have had hygiene needs met. Family member stated that a family member is present for part of every day of resident's stay. Family member did not have concerns for care of R1. R1 was not able to recall such an incident occurring. For the allegation of staff being rough with a resident and yelling at a resident, the specific resident was not identified and the staff are no longer present at the facility. No additional evidence was available for this allegation. Regarding the allegation of insufficient staffing, this complaint was stating general staff shortages that were alleged to occur months prior. Specific incidentsthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 59-AS-20250627153032

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not following refund conditions

On February 25, 2025, Licensing Program Analyst (LPA) Kevin Mknelly spoke with acting administrator , Cheryl Stevenson, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted interviews. LPA finds that the allegations cited above are substantiated. The complaint alleged that R1 paid a pre-admissions fee in July 2024, to reserve a room at the facility. R1 stated the licensee was not yet admitting residents at the time. R1 stated they changed their mind about moving in and went to the facility to let them know on October 7, 2024. R1 stated she spoke to the admissions coordinator. R1 stated they sent a letter on 10/24/24 stating they would not be moving in and requested a refund of fees paid to date. Report continued Substantiatedthe state’s words, verbatim · CDSS document, Feb 25, 2025 · control 59-AS-20250206153154

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.