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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920222
Report Date: 12/23/2025
Date Signed: 12/23/2025 02:26:13 PM

Document Has Been Signed on 12/23/2025 02:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
315920222
ADMINISTRATOR/
DIRECTOR:		SWEARINGEN, MICHELLEFACILITY TYPE:
740
ADDRESS:275 ROSEVILLE PARKWAYTELEPHONE:
(916) 432-2878
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 157CENSUS: DATE:
12/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Michelle SwearingenTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 12/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Administrator.

The department received an incident report that reported R1 having left the facility unassisted on 12/14/25. Resident returned unharmed approximately 50 minutes after their wander- guard recorded their departure. R1 was accompanied back to the facility by an apparent employee from a nearby shopping center.
Records review of R1's most recent physician's report lists: mild cognitive impairment, occasional disorientation, fall risk and unable to leave facility unassisted.
Staff interviews found that R1 has not had recent history of attempts to leave unassisted. Interviews also found that R1 had had recent discussions of wanting to get a haircut with family or staff assistance that were unsuccessful.
S1 was assigned to R1 at the time of R1's departure. S1 denies having been aware of a wander-guard alert of R1 exiting the building. S1 discovered R1 missing when S1 went to get R1 for a shower. S1 alerted others and searched the places R1 is known to go within the building.
S2 was working at the front desk at the time of R1's departure. S2 reported that the front lobby was busy at the time of R1's departure. S2 did not see R1 leave. However, S2 recalled other residents and family having been in the lobby. S2 stated that when the front door alarm sounds, staff would need to physically clear the alarm at the front door.
Report continued...
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/23/2025
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S3 was present at the time of R1's departure and saw R1 return to the building accompanied by another person. S3 stated they were not aware of R1's departure.
S4 was the med tech on shift but was on break at the time of the incident and only was aware of R1's return.
A review of this incident found the following factors to have allowed R1 to leave undetected: Staff at the front desk having too many tasks at the time to fully attend to resident departures, staff not receiving alerts on pagers; and, communication between staff to confirm that a exit alarm is properly responded to and the resident has not left without assistance.

Therefore, while there were sufficient number of staff, staff did not competently monitor R1 and respond to alerts of R1's exiting the facility.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2025 02:26 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 12/23/2025 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2025
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 interviews. This posed an immediate risk to R1.
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Licensee will submit the a summary of corrections put in place since this incident (to include front dest duties, wander guard alarm response procdure, equipment checks and staff communication for alarm responses). POC to be submitted by 12/23/25

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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.
Maribeth Senty
NAME OF LICENSING PROGRAM MANAGER:
Kevin Mknelly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2025


LIC809 (FAS) - (06/04)
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