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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920222
Report Date: 04/15/2026
Date Signed: 04/15/2026 02:41:55 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
12/26/2025 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20251226110029
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:
04/15/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michelle SwearingenTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility has insufficient staff to meet resident care needs.

Facility staff did not meet resident incontinence care needs.

INVESTIGATION FINDINGS:
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 On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with 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.
Title 22 personnell regulations require that staff be trained, competent and sufficent in number to meet the identified care needs of residents. One of the measures of sufficient staff numbers is in personnell records documentation of staff who actually worked per shift. This investigation was specifically reviewing staffing and care prior to January 1, 2026.

Based on review of staff schedules provided the following was found: Staffing for the month of Nov. 2025: 5- AM shifts with 2 caregivers/ 1 med tech; 5- days with 3 caregivers/ 1 med tech AM; 17- days with 4 or more caregivers/ 1 med tech AM; 1- day with 3 caregivers/ 1 Med tech PM; 29- days with 4 or> caregivers/ 1 med tech PM; 2- days with 1 caregiver ON; 9- days with 2 caregivers ON; and 19- days with 3 or> caregivers ON.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
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 8
Control Number 59-AS-20251226110029
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: 04/15/2026
NARRATIVE
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Staffing for the month of Dec. 2025: 5- AM shifts with 2 caregivers/ 1 med tech; 5- days with 3 caregivers / 1 med tech AM; 21- days with 4 or> caregivers/ 1 med tech AM; 1- day with 3 caregivers / med tech PM; 30- days with 4 or> caregivers/ 1 med tech PM; 12- days with 2 caregivers ON; and 19 days with 3 or> caregivers ON.

Staff interviews found that staff who worked during Nov. and Dec. 2025 experienced a number of staff leaving and new staff being hired.
Staff stated that given the duties and acuity of residents in memory care such as 2 person assists, incontinent care, bathing, dressing, monitor wanderers, fall prevention plans, assist with eating , laundry, serving/ bus tables, cueing, transfer assists and unexpected occurrences, if there are too few staff, they were unable to provide care as outlined in individual plans. While staff responses varied regarding the ideal number of staff, they uniformly stated that 3 experienced staff on AM/PM made it likely that there could generally provide care as outlined in care plans with minimal occurrences of delays in care and that AM/PM shifts with only 2 caregivers made it impossible to attend to resident needs timely.

LPA reviewed incident reports submitted by the program and conducted records review of seven residents for whom there had been reported incidents. Summary of the review:


R1- dementia diagnosis, food restrictions, incontinence, wandering/ exit seeking, confusion and aggressive episodes. RO records found incident for 11/26/25.
R2- dementia diagnosis, incontinence, transfer assistance and ADL assistance.
Incident reported for 10/16/25.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20251226110029
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: 04/15/2026
NARRATIVE
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R3- dementia diagnosis with extensive history of behavioral episodes, full assist with ADLs and incontinence care, required close observation for behaviors and inedible objects in their mouth. Incidents of falls, behavioral disturbances and sleeplessness on ONs.
R4- dementia diagnosis, vision impairment, incontinence, food preference. 8/30/25 incident.
R5- dementia diagnosis, food restrictions; incontinence assist, walker use/ wheelchair, confusion, "sundowning" and stand by assist for ADLs. Incident on 8/5/25 hospital care..
R6- Parkinson’s diagnosis with dementia, having CHF, hemiplegia and a catheter.
Incidents on 8/5/25, 9/6/25 and 9/6/25.
R7- Records found that R7, had a reported incident on 9/9/25 and has moved to assisted living before this investigation.

Interviews of staff and family regarding R1 found R1 to regularly wander within the memory care unit, trying to open doors and, at times, to enter other resident rooms. When resident care demands were high and staffing low, staff were not able to maintain awareness of R1’s status or location. R1’s service plan was for staff to “closely observe and guide wandering”. R1 would impulsively eat and had difficulty managing food. R1 was to be 1:1 staff assist while eating. R1 was twice hospitalized for aspirations, was observed by family, on one occasion following an aspiration hospitalization, with cheeks full of food. On one occasion, it was reported in interviews, R1 required another visitor to the facility to perform the Heimlich due to R1 choking (staff present at the time of the incident were not identified).
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 59-AS-20251226110029
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: 04/15/2026
NARRATIVE
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Interviews of staff and family regarding R6 found that R6 was known to be a fall risk and to have cognitive impairment that effected their ability to effectively use a call pendant and limited their awareness of their ambulation limitations. Family estimated R6 required cues/ reminders every 20-30 minutes in order to be more successful with their fall prevention plan. Staff interviews found that R6 quickly forgot safety information provided. R6’s assessment found a high level of care need. R1, according to staff interviews, would regularly be found on their floor without injury and R6 would be unable to explain how it occurred.

Interviews of staff and families also found R6 had a catheter and that catheter care of changing and flushing was done, in the community, by a family member who was not a licensed professional. This issue is addressed in an additional case management report.

While records and statements found a large variability in staff scheduled per AM/PM shifts, from 2 caregiver and a med tech to 4 (or more) caregivers and a med tech, the vast majority had at least 3 caregivers.
Staff statements that when there were 2 caregivers, for approximately 30 memory care residents, their main concern was safety. Resident ADL and incontinence care, schedules, monitoring could not be adhered to and posed potential risks to residents in care.

Title 22 requirements are that a resident with incontinence either have a

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 59-AS-20251226110029
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: 04/15/2026
NARRATIVE
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 structured bowel and/or bladder retraining program to assist the resident in restoring a normal pattern of continence or a program of scheduled toileting at regular intervals. Incontinence garments may be used.

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 Administrator . Copy of this report and appeal rights provide.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 59-AS-20251226110029
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: 04/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2026
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. This posed a potential risk to residents in care.
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Licensee is continually hiring and training staff to maintain numbers needed for the needs of residents.
Licensee will submit the plan for covering staffing needs when there are unexpected absence of staff, including reflecting the staff adjustment in the staff schedule.
Type B
05/13/2026
Section Cited
CCR
87625(a)(1)(BandC)
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Managed Incontinence (a)(1)(B and C) (B) A structured bowel and/or bladder retraining program to assist the resident in restoring a normal pattern of continence. (C) A program of scheduled toileting at regular intervals. This requirement was not met based on
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Licensee agrees to add to the plan above, how staffing will be responded to to specifically address the incontinence care plans for resident.
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records and statements. This posed a potential risk to residents in care.
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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: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
12/26/2025 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20251226110029

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:
04/15/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michelle SwearingenTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff insufficient care and supervision lead to resident pressure injury.

Staff insufficient care and supervision lead to residents choking on food incidents.

Resident was assigned a fee increase though care identified was not provided.
INVESTIGATION FINDINGS:
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On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Executive Director/ Administrator.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

Staff insufficient care and supervision lead to resident pressure injury – LPA reviewed records and statements regarding R5, who was found to have a recurring pressure injury on 8/5/25. Statements found that R5 received assistance with bathing from a family member and that family member notified facility staff of redness returning to R5’s previous pressure site. From statements received it appeared that it was agreed to monitor the site through the weekend. On 8/5/25, the wound opened and R5 was sent for emergency care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20251226110029
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: 04/15/2026
NARRATIVE
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Staff interviewed stated awareness of the monitoring and that in providing care, efforts were made to view the wound site. Staff also stated that R1’s behavioral expressions around bathing, dressing and incontinence care, coupled with family insistence on doing showers presented challenges to care and effective monitoring of the wound.

Staff insufficient care and supervision lead to residents choking on food incidents.- Interviews of staff and families found that there were incidents of residents choking on food or drink. However, LPA was unable to find a direct relationship between care and supervision and the occurrence of a particular incident.

Resident was assigned a fee increase though care identified was not provided- Health and Safety Code 1569.657 the licensee may increase residents’ care cost, following an reappraisal that identifies the increased care needed and provided. R5’s appraisals documented increased care needs that prompted a increase in fees. The licensee must then notify the resident and/or representative within two days of the increase.
Regulation requirements were followed and a meeting is available between the representative and facility staff to discuss the care and fees for R5.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Exit interview with administrator and report copy provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8