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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 08/14/2025
Date Signed: 08/14/2025 05:14:23 PM

Document Has Been Signed on 08/14/2025 05:14 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:		JAMES DIALFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 108CENSUS: 81DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:James DialTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit.

LPA Moleski reviewed five resident files (R1-R5) and five staff files (S1-S5).

LPA Moleski reviewed R1's file. R1's LIC 602 was dated 6/21/25. R1's move-in date was recorded as 7/28/25. R1's LIC 602 indicated that R1 had a pressure injury, but it was not staged. R1's LIC 602 indicated that R1 did not have home health services. In an interview, the facility's health services director (S6) said that they were not aware R1 had a pressure injury upon admission. An assessment for R1 dated 7/27/25 indicated that R1 did not have any wounds or bedsores. Dial said he received R1's LIC 602 from R1's previous placement on 7/25/25. LPA Moleski reviewed ongoing notes for R1. An "open area" was identified on R1's heel on 7/29/25, according to a note written on that same date. On 8/3/25, a "worsening condition of wound on left heel" was noted. The "top skin layer came off," and was "oozing and bleeding," according to the note. An incident report from 8/3/25 indicated that R1 was sent to the hospital, and S6 "started the process of obtaining a referral for home health" on that date. S6 said that R1 received no wound care at the facility prior to 8/7/25, when home health personnel visited for the first time. S6 said that they would have been able to secure a referral for home health prior to R1's admission if they were aware that R1 had a wound.

[continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: IVY PARK AT LAGUNA CREEK
FACILITY NUMBER: 347005512
VISIT DATE: 08/14/2025
NARRATIVE
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LPA Moleski reviewed R5's file and observed an LIC 602 dated 2/9/2022, and a second LIC 602 dated 8/1/2023. LPA Moleski asked for documentation of a routine annual visit within the last year. LPA Moleski was provided after-visit summaries for R5 from emergency room visits in December 2024 and April 2025 for confusion resulting from a UTI and a fall, respectively. Neither of these constitute routine annual visits evaluating general health.

LPA Moleski toured the facility with Dial and inspected common areas, kitchen areas, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

During LPA Moleski's tour, LPA Moleski and Dial observed a bottle of degreaser left unattended outside. LPA Moleski and Dial also observed that the facility maintenance director's office was unlocked. The office, which has a primary entryway leading from the common outdoor area, contained multiple cleaning solutions and potentially hazardous tools. In two separate memory care cottages, LPA Moleski and Dial observed lime scale remover and isopropyl alcohol left in unlocked cabinets, respectively.

LPA Moleski and Dial observed on the floor of a memory care cottage medication room one tablet of medication and one half of a medication capsule shell.

LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked carts used for the storage of medication.

LPA Moleski interviewed two staff members (S7-S8) and three residents (R4, R6-R7).

This facility is hereby cited per 22 CCR Sections 87631(a)(1), 87309(a), 87465(h)(5), and 87463(h)(1). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 05:14 PM - It Cannot Be Edited


Created By: Vincent Moleski On 08/14/2025 at 04:32 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 PARK AT LAGUNA CREEK
FACILITY NUMBER: 347005512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87631(a)(1)
"(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:

(1) When care is performed by or under the supervision of an appropriately skilled professional."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, a resident with a pressure wound was admitted to this facility without home health or other skilled medical supervision or instruction, resulting in the worsening of the wound over the course of several days, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Licensee agrees to conduct a training regarding intake procedures and restricted health conditions. Licensee agrees to provide LPA Moleski with a scheduled date for this training by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 05:14 PM - It Cannot Be Edited


Created By: Vincent Moleski On 08/14/2025 at 04:40 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 PARK AT LAGUNA CREEK
FACILITY NUMBER: 347005512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, multiple cleaning solutions and other hazardous materials were accessible to residents in care, including memory care residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Licensee agrees to schedule a staff training regarding storage requirements by POC due date and to notify LPA Moleski of the proposed date of training by POC due date.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medication was stored outside of its originally received container, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Licensee agrees to conduct a training regarding medication storage procedures by POC due date and to notify LPA Moleski of the proposed date of training by POC due date.
vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 05:14 PM - It Cannot Be Edited


Created By: Vincent Moleski On 08/14/2025 at 04:40 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 PARK AT LAGUNA CREEK
FACILITY NUMBER: 347005512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, a resident did not receive an annual routine visit with a medical practitioner, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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Licensee agrees to request a routine annual visit for this resident by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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