Ivy Park at Murrieta

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Facility did not provide resident transportation to medical appointments.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA met with Karen Lovett Businness Office Manager, and explained the purpose of the visit. The investigation consisted of observation, interviews, and record review. A review of documentation revealed that there was a discussion had between R1’s responsible party and the previous Administrator Matthew Murphy of transportation relating to R1 and their dialysis appointments in the city of Perris three times a week, prior to R1 moving into the facility. The documentation revealed that someone from the front desk, told R1s responsible party that transportation would in fact be provided. However, additional documentation revealed that R1 had to pay a private company so that they could be transported to their dialysis appointments. The previous Administrator Matthew did state that the wrong information was provided and that there would be a credit issued for $504.00 to R1s rent to cover the expenses for private transportation being utilized. ***Continued on 9099c Substantiated The current Administrator Billy Tames stated that the facility does provide transportation, and that it is normally for offices located in Murrieta, or within a 10-mile radius for medical and dental appointments, and that anything outside the ten miles is up to the discretion of the General Manager. The transportation days for Doctor’s and dental appointments are on (Mondays, Tuesdays, Thursdays) and shopping on (Wednesdays and Fridays). The transportation schedule reviewed has a note that states that “any other transportation on these days will be a $10.00 charge each way. A review of R1s signed monthly fee states that scheduled transportation is to be provided. It is not specified that extra fees will incur or that the office should be within a 10-mile radius. In addition, the facility does not have the transportation program in writing stating that the location to where transportation is needed should be in Murrieta and within a 10-mile radius, and that anything outside is up to the discretion of the General Manager. Therefore, the allegation of facility did not provide resident transportation to medical appointments is SUBSTANTIATED. An exit interview was conducted and a copy of this report, 9099D, LIC 811 (confidential names list) and appeal rights were provided to Karen Lovett, Business Office Manager. R1 stated that lost their footing and as they were falling, they pulled on the tubing in their chest out. Additional documentation reviewed revealed that R1 was admitted to the facility and noted in R1s service agreement that R1 presents a moderate risk for falls due to their medications, ambulatory status and history of dizziness, and that a plan to reduce the falls should be identified. In addition, on October 1, 2021, the facility’s LVN made a request for R1 to get started on physical therapy due to the number of falls that they experienced since moving into the facility. It further states that two of the four falls resulted R1 having to go to the hospital and that there is a concern for R1’s safety. Based on observation and record review the allegation is UNSUBSTANTIATED. Responsible party was not provided with details of resident’s move to memory care. Resident #1 (R1) was admitted to the facility on July 12, 2021 on the assisted living side of the community. Documentation reviewed revealed that R1’s responsible party did inquire prior to R1 being moving into the facility what moving from assisted living to memory care involved such as fees associated with the additional care that was to be provided. A review of documentation revealed that R1s responsible party was not notified that R1 required an increase in care until October 28, 2021. It was noted that a reassessment of R1s needs was completed and that R1 required additional care going from AL-level 1 to AL level 2. It was also noted that the facility back dated the date the additional services were provided, which was on October 8, 2021. However, there was no mention of it until October 28, 2021 to R1’s responsible party. Even though the facility did not inform R1’s responsible party at the time that they began providing R1 with additional services, R1 did not move into the memory care unit until November 11, 2021. In addition, documentation reviewed noted for R1s responsible party to be on agreement with R1s move to the memory care unit, Additionally, R1 was diagnosed with having dementia on November 13, 2021 when they were sent out to the emergency room after sustaining a fall.and that there was a previous discussion of fees associated with moving into memory care. Therefore, the allegation is UNSUBSTANTIATED. Resident was not given proper notice of price increases. Regarding the allegation resident was not given proper notice of price increases. LPA reviewed a letter addressed to R1 dated November 1, 2021 informing R1 that that facility completed a review of operational expenses that includes food, staffing ratios and other provided services, R1s monthly apartment fee will increase to $3,125 per month effective January 1, 2022. R1 was given a sixty (60) day notice about the increase in their rent, as well as their responsible party. The allegation of resident was not given proper notice of price increases is UNSUBSTANTIATED. Facility did not provide resident a proper bed. It was alleged that the facility provided R1 a cot to sleep on after they were discharged from the hospital with a broken humerus. Documentation reviewed dated November 16, 2021 reveals that the Memory Care Director Michelle DeFierra did inform R1’s responsible party that R1s bed would not be able to fit into the new room in the memory care unit. However, there was no further discussion of what would happen next, if R1 would in fact move into the room selected or if a different bed would be provided. It was reported that only a twin-size bed would fit into the room. R1 was provided with a roll away twin size bed the allegation of facility did not provide resident a proper bed is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to Karen Lovett, Business Office Manager.the state’s words, verbatim · CDSS document, Mar 21, 2023 · control 18-AS-20220126075930

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(8) · Plan of correction due date: Apr 4, 2023

87208 Operating requirements (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (8) Transportation arrangements for persons served who do not have independent arrangements. This requirement is not met as evidenced by: R1 was led to believe transportation would be provided to their dialysis appointments. However due to the location being outside of Murrieta, R1s transportation request was denied, forcing them to utilize a private transportation company, This poses a potential health, safety and personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Mar 21, 2023

Plan of correction: The licensee agrees to have a written transportation procedure. POC is due by 5pm on the due date indicated.

Allegation investigated: Facility staff not following resident's admission agreement. Facility staff not providing dignity to resident.

On March 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to the facility to deliver findings regarding the listed allegations. LPA Mixson met with Health & Wellness Director (HWD) introduced self and stated the purpose of the visit. On December 16, 2022, Community Care Licensing (CCL) received information regarding the listed allegations. LPA Mixson conducted interviews, record reviews, and observations in order to obtain additional information regarding the listed allegations. After LPA's assessment of interviews, documents, and other evidence received, there was not a preponderance of the evidence strand to demonstrate that the listed allegations did or did not occur. Therefore, the outcome of the investigation has been concluded with a finding of UNSUBSTANTIATED. A finding of "Unsubstantiated" means "although the allegation may have happened, or is valid there is not a preponderance of evidence to prove the alleged violation happened. Therefore the outcome of this investigation is deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to the Health & Wellness Director. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 20, 2023 · control 18-AS-20221216170549

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to provide services based on the resident's needs.

On March 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to deliver the findings on the listed allegations. LPA Mixson met with Health & Wellness Director, introduced self and stated the purpose of the visit. On 08/08/2022 Community Care Licensing (CCL) received information regarding the listed allegation. LPA Mixson conducted staff and resident interviews, record reviews, and observations. After LPA's assessment of the information there was not sufficient evidence to determine if the allegations are valid. Therefore, the outcome of the investigation is UNSUBSTANTIATED. A finding of "unsubstantiated" means "although the allegation may have happened or is valid, there is not a preponderance of evidence strand to prove the alleged violations did or did not occur. Therefore, the outcome of the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided to Health & Wellness Director, (HWD) JINA BORA. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 20, 2023 · control 18-AS-20220808162629

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Resident is being yelled at while in care. Staff denied a resident from disinfecting the facility. Staff is mistreating a resident while in care.

On March 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to deliver the findings on the listed allegations and to conclude the investigation. LPA Mixson met with Health & Wellness Director, introduced self and stated the purpose of the visit. On 12/09/2022, Community Care Licensing (CCL) received information regarding the listed allegations. LPA Mixson conducted staff and resident interviews, record reviews, and made observations in order to obtain additional information regarding the investigations. After LPA Mixson's assessment of the information received from the interviews, record reviews, and observations there was not sufficient evidence to determine if the allegations are valid. Therefore, the outcome of the investigation is UNSUBSTANTIATED. A finding of "unsubstantiated" means "although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the outcome of the listed allegations is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided to Health & Wellness Director. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 20, 2023 · control 18-AS-20221209130322

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff are not allowing resident to leave the facility.

On March 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to deliver the findings on the listed allegations. LPA Mixson met with the Health & Wellness Director introduced self, and stated the purpose of the visit. On 01/10/2022 Community Care Licensing (CCL), received information regarding the listed allegation. LPA Mixson conducted staff and resident interviews, record reviews, and made observations pertaining to the listed allegations. Information obtained from staff and resident interviews demonstrated that the Resident (R1) is a dementia resident in the memory care unit and is not able to leave the memory care unit unassisted. After the LPA's records review of the Physicians' Report, and the Admissions Agreement these documentation corroborated these statements to be accurate information. After LPA Mixson's evaluation of information obtained there was not sufficient evidence to determine if the allegation was valid. Therefore, the outcome of the investigation is UNFOUNDED. A finding of "Unfounded" means "the allegation is false, could not have happened and/or is without a reasonable basis." Therefore, the outcome of the allegation is deemed UNFOUNDED. An exit interview was conducted, and a copy of this report was provided to Health & Wellness Director, (HWD) JINA BORA. Unfoundedthe state’s words, verbatim · CDSS document, Mar 20, 2023 · control 18-AS-20230110143118

Type of visit: Case Management - Other

On March 20, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced case management visit to the facility. LPA Mixson met with Health & Wellness Director,(HWD) introduced self and explained the purpose of the visit. LPA Mixson toured the facility with HWD, currently there are 110 residents and 37 employees including caregivers. There are no imminent health and/or safety concerns observed at the time of visit. LPA Mixson observed facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA Mixson assessed the available food supply and observed that the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. Medications were found to be in sufficient supply as well. There were no missed doses or dates left blank for the current month. During the tour LPA Mixson met with and spoke with R1. Information obtained stated that there were no concerns or issues as the previous private care provider was let go the same day of the incident in question. R1 shared the new private care provider M,T, Th, & Friday 8:00am to 8:00pm. R1 shared she was fine and had no concerns. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to HWD.the state’s words, verbatim · CDSS document, Mar 20, 2023

Allegation investigated: Resident does not have access to belongings. Staff are trying to remove resident from facility under false information. Resident is not accorded dignity in relationship with staff.

On March 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to deliver the findings on the listed allegations. LPA Mixson met with Health & Wellness Director, introduced self and stated the purpose of the visit. On 08/22/2022 Community Care Licensing (CCL) received information regarding the listed allegations. Information obtained stated the Resident, (R1) does not have access to belongings, staff are trying to remove R1 from facility under false information, and R1 is not accorded dignity in relationship with staff. LPA Mixson conducted staff and resident interviews, record reviews, and observations. After LPA's assessment of the information there was not sufficient evidence to determine if the allegations are valid. Therefore, the outcome of the investigation is UNSUBSTANTIATED. A finding of "unsubstantiated" means "although the allegation may have happened or is valid, there is not a preponderance of evidence strand to prove the alleged violations did or did not occur. Therefore, the outcome of the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided to Facility Manager. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 16, 2023 · control 18-AS-20220808162629

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility is retaliating against resident.

Licensing Program Analyst (LPA) Javina George conducted an unannounced visit to the facility to commence a complaint investigation for the allegation listed above. LPA met with Michelle De Leon Ferreira and explained the purpose of the visit. Regarding the allegation of facility is retaliating against resident. LPA George conducted interviews and based on the information provided there was not enough evidence to corroborate the allegation. Resident #1 (R1) is diagnosed with a traumatic brain injury (TBI) and has recently has change in their mental condition involving threats to cause harm to thyself and others, as a result law enforcement assistance was required. During interviews LPA observed that R1 was paranoid and shared a lot of theories, but was unable to finish their thoughts. In addition, R1 admitted that they do have a law suit but it is not against the facility. Unfounded We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted, and a copy of this report was provided to Michelle De Leon Ferreirathe state’s words, verbatim · CDSS document, May 26, 2022 · control 18-AS-20220520103505

Allegation investigated: Resident is being discriminated against while in care. Resident is not being allowed visitations while in care. Food services are inadequate. Resident is being spoken to inappropriately while in care. Resident's personal belongings are not being safeguarded.

Licensing Program Analyst (LPA) Javina George conducted an unannounced visit to the facility to commence a complaint investigation for the allegation(s) listed above. LPA met with Michelle De Leon Ferreira and explained the purpose of the visit. The investigation consisted of observations, interviews with staff and residents, as well as resident file reviews. Allegation: Resident is being discriminated against while in care. LPA George conducted interviews and based on the information provided there was not enough evidence to corroborate the allegation. The residents denied being discriminated against or witnessing any discrimination. Therefore the allegation of Resident is being discriminated against while in care, therefore the allegation is UNSUBSTANTIATED. Allegation: Resident is not being allowed visitations while in care. LPA George conducted interviews and based on the information provided there was not enough evidence to corroborate the allegation of Resident is not being allowed visitations while in care. Unsubstantiated Residents reported that they do have visitors and their visits take place either in the area with a couch, outside and maybe even in their bedrooms. The facility is allowing visits regardless of vaccination status. Visits are being permitted 24 hours a day 7 days a week per Memory Care Manager, since things have begun to open back up. The vaccination cards are checked and on site rapid testing, and temperature is also completed. therefore the allegation is UNSUBSTANTIATED. Allegation: Food services are inadequate. LPA George conducted interviews and based on the information provided was that residents in care feel that they are getting enough to eat for all meals provided (breakfast, lunch, dinner) and that, they are allowed to get seconds without any issue if they have requested them. Based on observation and interviews the allegation of Food services are inadequate, therefore the allegation is UNSUBSTANTIATED. Allegation: Resident is being spoken to inappropriately while in care . LPA George conducted interviews and based on the information provided the overall consensus was that, staff speak appropriately to residents, by using an appropriate voice tone, and use kinds words (no profanity), and that they are all treated equally like adults. The allegation of Resident is being spoken to inappropriately while in care is UNSUBSTANTIATED. Allegation: Resident's personal belongings are not being safeguarded Based on feedback provided from the conducted interviews and record review. LPA found that there was not sufficient evidence to support the allegation. Resident's have a key to their bedrooms, and are encouraged to lock their doors. LPA observed staff reminding and assisting a resident with locking their door. Due to a lack of evidence the allegation of Resident's personal belongings are not being safeguarded is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to Michelle De Leon Ferriera, Memory Care Manager.the state’s words, verbatim · CDSS document, May 11, 2022 · control 18-AS-20220502141754

Type of visit: Required - 1 Year

On 05/11/2022 Licensing Program Analyst (LPA) Javina George conducted an unannounced annual inspection. LPA met with Michelle De Leon Ferreira, Memory Care Manager and explained the purpose of the visit. An overall tour of the facility was conducted of the interior and exterior, with a focused on the infection control practices that the facility has implemented. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). Staff were also observed wearing appropriate face coverings (surgical masks). The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA did not observe any of the required Covid-19 postings posted throughout the facility. However, the hand washing signs were re posted prior to LPA leaving the facility. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Michelle De Leon Ferriera, Memory Care Manager.the state’s words, verbatim · CDSS document, May 11, 2022