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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 09/03/2025
Date Signed: 09/03/2025 03:20:27 PM

Document Has Been Signed on 09/03/2025 03:20 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:		JAMES DIALFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 108CENSUS: 85DATE:
09/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:James DialTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation. However, during the course of that complaint investigation, LPA Moleski discovered an unrelated deficiency. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit.

During the investigation of complaint #27-AS-20250617103041, LPA Moleski interviewed Dial and a former resident's responsible party (R1's RP). Admission documents for R1 indicate that R1's RP was appointed R1's attorney-in-fact. R1 moved into this facility on 6/2/25 and moved out on 6/13/25. An allegation on complaint #27-AS-20250617103041 was that R1 was illegally evicted. This allegation was determined to be unsubstantiated. Based on interviews with staff, there was no formal notice to evict and no other written communication on the topic of R1's move-out, merely verbal conversations.

During an interview, facility staff (S1) stated that R1 was provided with one-on-one caregivers through an outside agency in order to supervise R1 during certain hours prior to R1's move-out. Facility staff (S1 and S2) voiced concerns over R1's tendency to seek exits and continued attempts to elope.

In an interview on 7/8/25, Dial said "we required [R1's RP] to get one-on-one" supervision. LPA Moleski asked specifically if R1's RP was "required" to acquire these third party services. Dial reaffirmed that R1's RP was required to do so. In an interview, R1's RP also stated that it was a "requirement" that one-on-one supervision be provided through a third-party prior to R1's departure from the facility. R1's RP said they paid "out of pocket" for these one-on-one caregivers for three or four nights. [continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
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: 09/03/2025
NARRATIVE
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Per 22 CCR Section 87468.1(a)(16), residents in all facilities have the right to "reject ... services." If additional care and supervision over a resident is necessary, facilities have the right to charge for additional in-house care costs per HSC Section 1569.657, but this requires an itemized bill and written notice at a minimum. Additionally, per 22 CCR Section 87464, care and supervision are basic services which must be provided by a licensed care facility to each resident. 22 CCR Section 87411(a) requires that staff be "sufficient in numbers ... necessary to meet resident needs."

This facility is hereby cited per 22 CCR Section 87468.1(a)(16). 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: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 03:20 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Vincent Moleski On 09/03/2025 at 02:14 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: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
09/04/2025
Section Cited
CCR
87468.1(a)(16)

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"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: ... (16) To receive or reject medical care or other services." This requirement was not met as evidenced by:
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Licensee agrees to review the sections referenced in this report and to write a signed statement acknowledging that residents, and by extension their designated attorneys-in-fact, cannot be required to acquire third-party care or supervision services, by POC due date. vincent.moleski@dss.ca.gov
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Based on interviews, facility staff "required" a resident's attorney-in-fact to acquire and pay for third-party one-on-one caregivers, which poses an immediate personal rights risk.
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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: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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