Ivy Park at Santa Rosa

Type of visit: Case Management - Incident

At approximately 3:00pm LPAs Christi Coppo and Victoria Bertozzi arrived unannounced to conduct a case management regarding Incent Report received on 10/06/2023. Per facility’s Incident Report: On 10/05/2023 a visitor came to visit resident (R1), upon looking for R1 it was discovered that R1 was not in the facility. The last time R1 was accounted for was at approximately 2:15pm while engaging in activities in the community living room. R1 has a diagnosis of dementia and resides in Memory Care. Staff located R1 at approximately 5:15pm at the Santa Rosa Memorial Hospital Emergency room. R1 was evaluated at the hospital’s ER and was found to have no injuries, no new diagnoses, or new medication orders. R1 was released from hospital’s ER at approximately 6:07pm. LPAs reviewed R1’s assessment and clarified resident has known exit seeking behavior. Per LPAs’ conversation with Administrator, facility immediately conducted additional training with staff. Also, Administrator has increased staff monitoring of R1. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. This report was reviewed with Administrator and Appeal rights were given.the state’s words, verbatim · CDSS document, Oct 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 20, 2023

87705 Care of Persons with Dementia (c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: based on document review, Licensee did not meet requirement by R1 eloping a locked memory care unit. This poses a potential Health, Safety or Personal rights risk to residents.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Facility immediately conducted additonal training with staff. Also, Adminstrator has increased staff monitoring of R1 and increased activities. Deficiency is cleared.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Case Management-Incident inspection to discuss three incidents that were reported by the facility to CCL, and to also Amend a Report that was issued on August 30, 2023 in which a Type A deficiency was issued. Facility appealed, and CCL determined that a Type B deficiency is warranted instead. LPA changed the deficiency from a Type A to a Type B deficiency (See LIC 809-Case Management-Incident inspection dated for August 30, 2023) CCL received an incident report on September 20, 2023 indicating a residents jewelry went missing. Administrator contacted the appropriate parties which includes the Responsible Party via email. LPA requested the following documents: -LIC 602 CCL received an incident report on September 25, 2023. Resident had a left hip fracture due to falling off a chair that was placed in his apartment. Administrator contacted the appropriate parties which includes the Responsible Party. Resident was not a fall risk and there were no prior fall incidents regarding this resident. Facility will reassess resident and determine what additional needs (if any) are needed for this resident. CCL received an incident report indicating a fall that occurred on September 27, 2023 indicating that there was one rodent (rat) that was an apartment. Administrator cleaned, fumigated and eradicated the room. In addition, facility hired a pest control company to ensure that there was no rodent infestation. LPA requested the following document: -Eco-Lap pest control receipt No deficiencies were observed or cited during today's Case Management-incident inspection. Exit interview was conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Oct 3, 2023

Type of visit: Case Management - Incident

"AMENDED" This is an amended version of the original report created on August 30, 2023 which a Type A Deficiency as issued. Facility Appealed and CCL determined that a Type B deficiency is warranted. LPA is Amending this report from a Type A deficiency to a Type B deficiency. (See LIC 809D for the change) Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Ivy Park at Santa Rosa for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by the receptionist, Sony Pastor. Administrator arrived 20 minutes later. During this Case Management-Incident inspection, LPA interviewed the Administrator and attempted to interview two residents in care, but were unsuccessful. LPA reviewed training documents regarding Staff Member #1 (S1). LPA learned that during the incident in question, emails depicting inappropriate photos of two residents in placement were sent to the Administrator via a cellular device and by email (See LIC 809D). LPA learned that the staff member was written up for the alleged photography. LPA educated the Administrator regarding that photography of residents are not to be taken on personal cell phones. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview was conducted with the Administrator and appeal rights were emailed.the state’s words, verbatim · CDSS document, Aug 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(3) · Plan of correction due date: Aug 31, 2023

Health and Safety Code 1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law. This requirement was not met as evidenced by: Based on an interview with the Administrator, LPA learned that during the incident in question, emails depicting inappropriate photos of two residents in placement were sent to the Administrator via a cellular device and by email which is an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2023

Plan of correction: Plan of Correction was already completed via in-service training conducted on July 2023. LPA requested the Administrator to submit an LIC 9098-Self Certification and a summary on how future compliance will be met. Plan of Correction due on August 31, 2023.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Ivy Park At Santa Rosa for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Administrator, Stephanie Limberg, and was granted access into the facility. During the Case Management-Incident inspection, an incident report was forwarded to Community Care Licensing Regional Office on June 10, 2023. Incident Report summarizes that a resident had a fall, injury and subsequent hospital visit. LPA learned that the resident is doing good at this time and was prescribed some medication for the pain throughout the night. Administrator shared that the Care Plan will be updated with the family. LPA attempted to interview the Resident in care and was unsuccessful. During this Case Management-Incident Inspection, LPA reviewed the following document: -Care Plan No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.the state’s words, verbatim · CDSS document, Jun 22, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Ivy Park At Santa Rosa for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Administrator, Stephanie Limberg, and was granted access into the facility. During the Case Management-Incident inspection, LPA requested the following document for an incident that was submitted to CCL on April 22, 2023: -LIC 602 During the Case Management-Incident inspection, LPA reviewed the LIC 602 at the facility and found that the resident was NOT on a Special Diet. Furthermore, facility followed all proper procedures as it relates to this incident report. Also on this date and time, LPA followed up with another incident report that was submitted on May 5, 2023 regarding a resident to resident altercation at the facility. LPA interviewed the Administrator and the two residents. LPA learned that both residents have no recollection of what occurred and have assimilated back into the community. Furthermore, LPA learned that the Care Plans will be updated for both residents in care. No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.the state’s words, verbatim · CDSS document, May 8, 2023

Allegation investigated: Staff interferes with resident visiting at the facility

***Amended Report*** Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced on to deliver amended the amended report originally dated for February 23, 2023 by Licensing Program Analyst (LPA), Erik Gonzalez Campos . LPA was greeted at the door by Business Office Manager, Debbie Spencer and was granted access into the facility. LPA reviewed records and conducted interviews. LPA attempted to contact Resident 1’s (R1) Durable Power of Attorney (DPOA) on record. DPOA was not reachable. LPA contacted family listed in resident file who expressed no concerns regarding visitation of R1. Reporting Party (RP) also indicated that they have been allowed to visit R1 on multiple occasions. Per staff interviews, no one has been denied entry to visit R1. LPA toured memory care unit and observed R1 in the bedroom. R1 appeared to be in no distress. Based on the investigation, the allegation is unfounded meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted with administrator, Lydia Gravelyn. Report was emailed to admin. No deficiencies observed during today’s inspection. Unfoundedthe state’s words, verbatim · CDSS document, Feb 23, 2023 · control 21-AS-20221219120741

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/23/2023 to conduct a required - 1 year inspection. LPA was greeted and screened by staff. LPA met with administrator, Lydia Gravelyn. This inspection is focused on the infection control practices and procedures of this facility. LPA toured building and grounds which were found to be clean and in good repair. Facility had sufficient perishable and non-perishable food. Fire extinguishers inspected were charged and current. Toxins were locked and secured. Medications were centrally stored and locked. Carbon monoxide and smoke detectors were present and operational. Walkways were cleared and unobstructed. High touch surface areas are disinfected daily. LPA observed COVID postings at the front entrance. Staff and residents are all fully vaccinated. Facility has necessary Personal Protective Equipment to support a resident in isolation. LPA and administrator discussed resident/staff record keeping. Staff have been given infection control training. LPA requested the following documents be submitted to Community Care Licensing within 30 days of today's inspection: LIC 308 Designation of Facility Responsibility Liability Insurance LIC 610 Emergency Disaster Plan LIC 9020 Resident Roster LIC 500 Personnel Report Admin Certificate No deficiencies observed during today's inspection. Exit interview conducted with administrator and a copy of the report emailed to facility.the state’s words, verbatim · CDSS document, Feb 23, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/28/2022 to conduct a case management inspection. LPA met with administrator, Lydia Gravelyn. Case management is regarding a self reported SOC341 received by Community Care Licensing on 12/20/2022. Facility has conducted an internal investigation and reported incident to the Santa Rosa Police Department. LPA will follow up by requesting police report. No deficiencies cited during today's inspection. Exit interview conducted with administrator and a copy of this report emailed to the facility.the state’s words, verbatim · CDSS document, Dec 28, 2022

Allegation investigated: 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

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 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.the state’s words, verbatim · CDSS document, Dec 16, 2022 · control 21-AS-20220816152630

Allegation investigated: Resident sustained an unwitnessed fall resulting in injuries while in care. Resident sustained skin tears while in care.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Lydia Gravelynand discussed findings. This Department has investigated allegations by conducting interviews; reviewing documents and photographs; making site visits to facility. The following determinations are made: R1 sustained unwitnessed fall on 1/19/2022; initial assessment of 1/11/2022 notes R1 can transfer independently and does not require assistance; Staff report that R1 had been checked prior to fall within the hour; Staff summoned medical attention and made the required notifications. On 5/17/2022, staff noted a fresh skin tear on R1; Facility LVN assessed and dressed the tear and made required notifications; Seen by a MD on 5/23/2022, R1 was noted to have no signs of infection or abuse; MD reports that the injury consistent with a fall. This Department has investigated the complaint allegations and, based upon the statements taken and documents reviewed, we have determined that the complaint is UNFOUNDED, meaning that the allegations are false and/or, are without a reasonable basis. The complaint is DISMISSED. Report left. Unfoundedthe state’s words, verbatim · CDSS document, Nov 22, 2022 · control 21-AS-20220531090701

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 25, 2022

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. ***Based upon statements and photographs this requirement has not been met as evidenced by: Facility failed to arrange timely podiatric care for R1 which resulted in excessively long nails and toes in need of care. This posed an immediate risk to the health and personal rights of the resident in care.the state’s words, verbatim · CDSS document, Nov 22, 2022

Plan of correction: Facility Management will provide a written plan which outlines action to be taken by facility going forward which addresses how residents’ podiatric needs will be timely met, including circumstances when family is not available to transport and/or, provide the care. Plan to be submitted to CCL by POC date in order to clear the deficiency.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Post-Licensing Inspection. Listed administrator is no longer with the facility. LPA met with Regional Memory Care Specialist, Tammy Kirby. Building and grounds were found to be clean and in good repair. Facility is conducting COVID screening at the front entrance for visitors. LPA was screened by staff. All staff have been vaccinated and boosted. Facility does not currently conducting surveillance testing. Staff were observed wearing masks. LPA and Regional Memory Care Specialist discussed infection control plan. Regional Memory Care Specialist indicated no policy changes regarding visitation and infection control. Facility to submit plan later this month. Personal Protective Equipment is available to support a resident in isolation. Facility will submit documents to change administrator for the facility. Medications are centrally stored and locked making them inaccessible to residents. Toxins are secured and inaccessible to residents. During tour of memory care LPA observed two fire extinguisher behind locked cases. Staff stated that the maintenance coordinator has the key but they do not. LPA is requesting written plan be submitted to Community Care Licensing indicating how facility plans to give fire extinguisher access to memory care staff by July 1, 2022. Exit interview conducted with Regional Memory Care Specialist, Tammy Kirby.the state’s words, verbatim · CDSS document, Jun 24, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Case Management Inspection. This inspection is regarding an incident report received by Community Care Licensing (CCL) on 06/09/2022. LPA met with Regional Memory Care Specialist, Tammy Kirby LPA toured Memory Care Unit. There are currently 31 residents in care. LPA observed that exits to the outdoor patio areas and the front entrance are all armed with alarms. Off of the dining area there is an alarmed door which will open but sound the alarm unless a code is entered. This door leads to a patio area. In the patio area there is a delayed egress door. Door will sound alarm for approximately 15 seconds before it pushes open. Alarms will page all staff in memory care unit. On June 8, 2022 a resident eloped from memory care and was found sitting on the bench in front of the assisted living community across from the parking lot. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Regional Memory Care Specialist, Tammy Kirby.the state’s words, verbatim · CDSS document, Jun 24, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Jul 1, 2022

87705 Care of Persons with Dementia (b)(2) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Based on LPA record review, interview and osbervation, R1 was able to exit one alarmed door and one delayed egress door which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2022

Plan of correction: Licensee to submit safety plan to community care licensing by POC due date 07/01/2022 indicating how they plan to prevent residents in memory care from exiting the building. Licensee to provide training to memory care staff on elopment procedures and to submit signed list of staff who were trained to CCL by POC due date 07/01/2022.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 06/02/2022 and met with Executive Director, Safoora Ahmed. LPA conducted a visit to return file for resident (R1). Executive director reviewed contents of file and and confirmed file was returned complete and undamaged per regulation. Exit interview conducted with administrator and a copy of this report emailed to the facility.the state’s words, verbatim · CDSS document, Jun 2, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 4/15/2022 to conduct a Pre-licensing inspection. LPA was greeted by staff and screened for COVID symptoms. LPA met with Health Services Director, Teresa Weerts. Facility is a two story building with assisted living and a memory care unit. LPA toured facility with health services directors. Rooms contained appropriate furnishings. Bathroom showers had the necessary grab bars and nonskid flooring. Water temperature tested at one sink accessible to clients was measured at 112.2 degrees F which is within regulation. Carbon monoxide detectors were observed as well as smoke alarms and a sprinkler system. Fire extinguishers were observed which were last inspected on 1/22/22. Toxins were locked and inaccessible to residents. Medications were also determined to be kept secured and inaccessible to residents in care. The memory care unit has a locked medication room. Assisted living has locked medication carts and central medication storage. Sufficient perishable and non-perishable food was observed in the kitchen. LPA observed licensing posters, complaint posters, an activity schedule, and ombudsman poster. There is an operating resident council. LPA conducted record review. LPA reviewed 5 resident files which included Physician's Reports, resident assessments, and admission agreements. There are two separate files for residents, a medical file and an administrative file. Admission agreements found in the administrative file. CPR and First Aid Certificates for staff are kept in a binder. 10 Current CPR certificates were observed. LPA reviewed CPR/First Aid regulation with health services director. Component III waived due to licensee operating a current licensed facility. LPA requested proof of liability insurance during inspection and application for new administrator. LPA will notify Application Unit so application process may proceed.the state’s words, verbatim · CDSS document, Apr 15, 2022

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 114 Census (if any clients in care): COMP II by CAB successfully completed Method: Telephone call KATHLEEN OLSON COMP II Participant: Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Feb 24, 2022