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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920222
Report Date: 11/18/2025
Date Signed: 11/18/2025 01:04:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2025 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250919152445
FACILITY NAME:IVY AT BLUE OAKS, THEFACILITY NUMBER:
315920222
ADMINISTRATOR:SWEARINGEN, MICHELLEFACILITY TYPE:
740
ADDRESS:275 ROSEVILLE PARKWAYTELEPHONE:
(916) 432-2878
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:157CENSUS: 104DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Michelle SwearingenTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff did not respond to resident call for assistance due to insufficient staffing.
Facility staff did not provide identified care assistance to resident.
INVESTIGATION FINDINGS:
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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...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20250919152445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: IVY AT BLUE OAKS, THE
FACILITY NUMBER: 315920222
VISIT DATE: 11/18/2025
NARRATIVE
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Staff stated that when they became aware of the call for assistance to R1, staff had to complete assistance with another resident on the second floor. Some staff reported that pagers used by staff were unreliable- sometimes not working and sometimes delayed signal. Management denies hearing of such issues with pagers. Staff, responding to R1 on 8/28/25, were told by R1’s spouse that they had been calling for assistance for a half an hour.
Additionally, it was reported that after waiting for call button response, R1’s spouse, reportedly, called to the front desk before assistance arrived. Therefore, it is found that personnel were not sufficient in numbers to meet the needs of residents.

Records and statements found that on 6/28/25, R1 was hospitalized for an acute health condition. Following their return to the community, R1’s services plan was increased to include evening and overnight assistance for R1’s safety . Statements by staff and the Administrator found that the increased assistance was not consistently provided as agreed to R1 during this time. R1’s condition improved to no longer needing the increased assistance. The service was discontinued and R1 was reimbursed for the lapse in increased care. Therefore, personal assistance and care, as identified, was not provided to R1 and as indicated in R1’s service agreement.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed with . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20250919152445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IVY AT BLUE OAKS, THE
FACILITY NUMBER: 315920222
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/12/2025
Section Cited
CCR
87411(a)
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Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met based on records and statements finding
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Licensee will submit the procedure of how the number of staff is determined per shift and how substitute staffing will be filled when scheduled staff do not work.

This POC is due by 12/12/25.
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insufficient number of staff.This posed a potential risk to R1.
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Type B
12/12/2025
Section Cited
CCR
87464(f)(4)
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Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated… This requirement was not met based on records and statements finding R1 returned with a change of condition and care needs identified were not provided. This posed a potential risk to R1.
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Licensee will provide a copy of procedures for identifying changes to resident care and identified chain of command to implement updates to resident care to all care staff.

ThisPOC is due by 12/12/25.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
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