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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 12/10/2024
Date Signed: 12/10/2024 12:20:53 PM

Document Has Been Signed on 12/10/2024 12:20 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:IVY PARK AT LAGUNA CREEKFACILITY NUMBER:
347005512
ADMINISTRATOR/
DIRECTOR:		MICHELLE SWEARINGENFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 108CENSUS: 63DATE:
12/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:James DialTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with director James Dial and explained the purpose of the visit.

LPA Moleski reviewed an incident report that was sent to the Community Care Licensing Division (CCLD) on 12/4/24. The incident report described a medication error which was discovered on 11/27/24 by a medication technician (S1). S1 had attempted to get a refill for a resident's (R1's) thyroid medication on that date, but was told that the medication was not able to be refilled, as there should be doses remaining, according to the incident report. The incident report stated that there was only one pill of the medication remaining at that time. In an interview, S1 said the medication, given in the correct dosage, should have lasted through 12/26/24. In an interview, the facility's health services director (S2) said that both night shift medication technicians (S3 and S4) had been giving one full pill of the medication, rather than the half pill prescribed. S2 said that they asked both S3 and S4 separately what they had been giving R1, and they both reported that they were giving one full pill. This had occurred on multiple occasions, according to the incident report.

Neither S3 nor S4 were present at the facility during this visit. LPA Moleski reached out via telephone to each but did not receive a response during this visit.

This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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Document Has Been Signed on 12/10/2024 12:20 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Vincent Moleski On 12/10/2024 at 10:18 AM
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 PARK AT LAGUNA CREEK
FACILITY NUMBER: 347005512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/11/2024
Section Cited
CCR
87465(a)(2)

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"(4) The licensee shall assist residents with self-administered medications as needed."

This requirement was not met as evidenced by:
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Licensee agrees to conduct staff training regarding medication administration.
vincent.moleski@dss.ca.gov
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Based on interview and record review, a resident did not receive medications as prescribed, which poses an immediate threat to health, safety, or personal rights.
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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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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