Ivy Park At Rockville

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the disposition. Through statements and document reviews it has been determined that R1 was prescribed Tramadol to be dosed 1/2 50 mg tab at bedtime as needed for pain but was administered 50 milligrams on several occasions in December, 2024, including 12/09, 12/15, 12/22; and some doses were given twice a day at times other than bedtime. Facility Administration has acknowledged the errors and has taken steps to retrain staff and place protocols in place to avoid future errors. Based upon the statements and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficienciRead the full finding— CDSS inspection report, January 21, 2025 · control 21-AS-20241226085057

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with **** and discussed the disposition. Complainant has alleged that facility staff are not responsive to Complainant's needs and cites having to wait for transportation to appointments, not responding timely to calls for assistance and making threatening remarks to Complainant. This investigation included a review of documents and taking of statements from parties and witnesses. Facility staff deny the allegations. A review of the facility policy regarding transportation for residents suggests that reasonable accommodations are made for the residents, including the Complainant. Complainant did not initially provide a date that staff did not respond in a timely manner and, when pressed, gave a date subsequent to the lodging of this complaint. This investigation found no evidence that staff have threatened the Complainant but did determine that exceptional efforts werRead the full finding— CDSS inspection report, December 17, 2024 · control 21-AS-20241105153420

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint and met with *****.Complainant alleges resident care needs not being met, staff smoking marijuana on the premises and cleaning supplies accessible to residents in care. Complainant informed care needs are not being met not limited to hygiene and dental care. The 10-day complaint inspection was conducted on 8/29/2024 by LPA Hansen. Hansen made observations, obtained resident records, and conducted interviews. During the course of the investigation, it was revealed that resident (R1) was admitted to the facility 11/2022 and vacated 6/2024. R1’s current service plan signed on 11/12/2023 indicated that R1 was a level 1 needing minimal assistance with ADLs. Medical assessment obtained dated 7/10/2023 supported care needs and indicated R1 has been doing better with supervision. The Department received photos and a document signed by dentist dated 6/12/2024 indicating poor dental hygRead the full finding— CDSS inspection report, December 3, 2024 · control 21-AS-20240823135406

Licensing Program Analyst (LPA) arrived unannounced to deliver findings on this complaint. Based upon information obtained during this investigation, which included interviewing staff and outside parties and record reviews, the above allegations are UNSUBSTANTIATED. Interviews and record review revealed resident listed as R1 requires “maximum assistance” with toileting, transfers, mobility, bathing (2x per week), dressing, grooming and medication management. R1 requires “moderate assistance” with coordination of outside agencies and oral hygiene. Service Plan dated 8/11/2024 corroborates the information above and details the assistance required, per Service Plan, R1 is a level 4. An updated Service Plan on record, dated 10/31/2024, shows R1 requires “maximum assistance” with toileting, transfers, mobility, bathing (2x per week), dressing, grooming, medication management and special needs – safety checks 4x per shift and rolling out of bed. R1 requires “moderate assistance” with coordinRead the full finding— CDSS inspection report, November 19, 2024 · control 21-AS-20241018122417

Licensing Program Analyst Leibert arrived unannounced in response to the allegation the facility has bed bugs. LPA met with Executive Director Carol Dowell. Based on a review of records which includes service orders and receipts from Clark Pest Control, interviews with staff and outside agencies the allegation of “facility has bed bugs” is SUBSTANTIATED. Facility reported September 23, 2024 was the first sighting of a bed bug in the facility, it was brought to the attention of staff who reached out to Clark Pest Control the same day. Clark conducted on inspection on September 24th. Residents and responsible parties in the areas impacted were notified via a letter, copy provided to the Department. September 26, 2024 Clark set-up the first heat treatment in two (2) rooms in the facility. On September 27, 2024, Clark returned to treat eight (8) additional rooms, they received a bio-spray treatment to ensure the bedbugs do not spread. On September 27, 2024 Clark did an in-service trainingRead the full finding— CDSS inspection report, October 22, 2024 · control 21-AS-20241016223345

On 5/16/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Carol Dowell. LPA toured the facility, interviewed Administrator and outside parties, reviewed resident medical and facility records and made observations during the course of the investigation. Complaint alleges resident (R1) continence care needs not being met. Based upon interview with outside Home Health Agency Lead Staff (I1), LPA found that there are multiple documented incidents in which R1 had been observed in soiled continence briefs when received by home health nurse (I2). In addition, R1's physician's report indicates that R1 has a bowel and bladder impairment condition indicating an increased level of supervision for R1's continence care needs which is documented on R1's Service Plan. Allegation, continence care needs not being met is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATEDRead the full finding— CDSS inspection report, May 16, 2024 · control 21-AS-20240220181337

Licensing Program Analyst (LPA), Farhaan Saragi arrived unannounced at Rockville Terrace Senior Living for the purpose of delivering complaint findings. LPA was greeted at the door by, Assistant Administrator, Hannah Richardson, and was granted access into the facility. Administrator arrived 30 minutes later. During the course of the investigation, LPA Sarangi reviewed residents Medication Assessment Records, facility records and interviewed staff. Complaint alleges that Staff do not provide proper medication assistance to resident in care. Based on an observation of the Medication Assessment Record (MAR) that was conducted, LPA learned that during the months of April 2023 there were gaps in the administration of medication for multiple medications which included eye drops for Resident #1 (See LIC 9099D). A former staff member missed the administration of eye drops on April 19-23, 2023, April 27 & 28, 2023 and April 30, 2023. An interview with the Administrator confirmed the missed medRead the full finding— CDSS inspection report, October 4, 2023 · control 21-AS-20230918161317

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. On 8/22/2023 Complainant alleged that the facility did not repair a leaking air conditioning unit and that the issue was reported three weeks prior. Administration claims the repair request was made one week prior and that maintenance attempted to repair the unit unsuccessfully which necessitated ordering parts and, ultimately, a new unit which was installed on September 4, 2023. Investigation indicates the facility made reasonable efforts to repair and replace the unit and that the apartment was observed to be a comfortable temperature at the time a site visit was made. Administration further reports that the apartment contains two AC units and that the apartment was kept within the temperature range required by Title Twenty-Two regulation 87303(b)(2) at all times. Although this allegation may be true, based upon the statements made, documents reviewed, as well as site visitRead the full finding— CDSS inspection report, September 21, 2023 · control 21-AS-20230822094748

**Amended from original report dated 8/29/2023. Original report was signed by Josephine Garcia-Evans. Amended report dated 9/7/2023 is signed by Administrator, Carol Dowell.** Licensing Program Analyst Leibert (LPA) arrived unannounced to deliver complaint investigation findings. The Department toured the facility, interviewed residents, reviewed resident records and made observations. Complaint alleges staff did not assist resident (R1) as needed/required regarding services for ambulation and assistance upon medical appointment check-ins. Based upon a review of R1’s resident records including Physician’s Report, Resident Appraisal and Resident Assessment; although R1 is non-ambulatory and utilizing a walker, there is no indication that R1 requires or is to be provided these additional services from the facility with ambulation assistance, transferring or mobility. This agency has investigated the complaint alleging staff did not assist resident as needed/required. We have found that tRead the full finding— CDSS inspection report, August 29, 2023 · control 21-AS-20230803132825

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of delivering complaint findings. LPA was greeted at the front door by Administrator, Carol Dowell, and was granted access into the facility. During the course of the investigation, LPA Sarangi reviewed resident(s) records, facility records, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. Complaint alleges that Staff do not meet residents' incontinence needs and staff do not assist resident with grooming. Based on interviews that were conducted throughout the investigation, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation. (Report continued on LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, May 15, 2023 · control 21-AS-20230322143424

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of delivering complaint findings. LPA was greeted at the front door by Care Coordinator, Josephine Garcia-Evans, and was granted access into the facility. Administrator arrived 15 minutes later. During the course of the investigation, LPA reviewed resident records, facility records, interviewed staff and a resident in care. Complaint alleges Personal Rights. During the course of the investigation, LPA interviewed facility staff and learned that a former staff member was verbally arguing with Resident #1. Furthermore, during an interview with the former staff member on March 24, 2023, LPA learned that there was a verbal altercation with Resident #1, and that her boss was notified of the altercation with the Resident. Subsequently, the former staff member was terminated due to the incident (See LIC 9099D). (Report continued on LIC 9099C) SubstantiatedRead the full finding— CDSS inspection report, April 11, 2023 · control 21-AS-20230214132130

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of interviewing the Administrator and delivered complaint findings. LPA was greeted at the front door by Administrator, Mikayla Muehleisen and was granted access into the facility. During the course of the investigation, LPA reviewed resident records, facility records, Program Plan of Operation, interviewed staff, witnesses and resident in care. Complaint alleges that Staff did not allow family members to visit resident in care. LPA conducted interviews with staff and a resident. LPA learned throughout the course of the investigation that on January 17, 2023 a visit was barred for one visitor that came to visit a resident. During a subsequent complaint investigation inspection on February 14, 2023, LPA and Administrator reviewed the Visitors Log for said date and no names were reflected on the Visitor Log for the said date. (Report continued on LIC 9099C) SubstantiateRead the full finding— CDSS inspection report, February 14, 2023 · control 21-AS-20230209115409

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of delivering complaint findings and interviewing an additional resident. LPA was greeted at the door by Administrator, Mikayla Muehleisen, and was granted access into the facility. During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. LPA reviewed facility documents including but not limited to staff roster, resident roster and food menu. Complaint alleges that facility does not meet resident's dietary needs. Based off of interviews that were conducted with additional residents and staff, LPA could not prove or disprove that the facility does not meet resident's dietary needs due to inconsistent statements made during the course of the investigation. LPA could not corroborate the allegation. (Report continued on LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, January 9, 2023 · control 21-AS-20221025110016