Ivy Ridge Assisted Living

Clean linen quantity and hygiene supplies

Store centrally held medications in locked secure place

87465(h)(2) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees. This requirement was not met as evidence by.Based on observation, inspection, and interviews, the Licensee did not ensure medication were kept in a safe locked place and made inaccessible to residents in care. This posed an immediate health and safety risk to residents in care.

Care and supervision as defined by statute and rules

Basic Service 87464(f)(1):(f) Basic services shall at a minimum include:Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: based on observation and interviews, the Licensee did not ensure to provide basic service to R1's and address R1's skin integrity/skin tears. This poses an immediate health and safety risk to R1.

Certified administrator requirements and substitute coverage

87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement is not met as evidenced by:Based on observations, interviews and record reviews, the licensee did not comply with the section cited above. The administrator Hong Trinh was not at the facility for a sufficient numbers of hours to permit adequate permit adequate attention to the management of the facility. This poses a potential health, safety or personal rights risk to persons in care.

Maintain cleanliness and prevent incontinence odors

87625(b)(3) Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.This requirement is not met as evidenced by: Based on observations on 04/16/25 and 06/05/25, LPA Lee observed incontinence smell in the facility. This poses a potential health, safety or personal rights risk to persons in care. This poses a potential health, safety or personal rights risk to persons in care.

Document each PRN medication dose taken

Based on observation and record review the licensee did not comply with the section cited above. LPA reviewed 2 out of 5 residents oh hand medications and medication administration record (MAR) and it was incomplete. Two of the resident’s medications are found in the resident’s medication box; however, they are not documented in the MAR logs. Which poses/posed a potential health, safety or personal rights risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on observation, the licensee did not comply with the section cited above. LPA Lee observed 3 out of 5 resident's bathroom didn't have non-slip which poses an immediate health, safety or personal rights risk to persons in care.

Food quality controls and rejected damaged goods

87555 General Food Service Requirements(b) The following food service requirements shall apply:(8) All food shall be of good quality…This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. Administrator didn’t ensure that multiple 2 days perishable food in the freezer had an expiration date. During interview when question the expiration date on the packages of 2 days perishable 3 facility staff stated, “I don’t know.” This poses an immediatehealth, safety or personal rights risk to persons in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply:(15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. Administrator didn’t ensure that food services sanitation practices are conducted when LPA observed facility staff now wearing gloves and hair net. It was also observed chicken was left to thaw out in the kitchen sink inside a bowl with water. This poses an immediate health, safety or personal rights risk to persons in care.

Give PRN medication by physician order

87465(c)(2): Incidental Medical and Dental Care(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN….(2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidence by: Based on observation, medication review and interview (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered; therefore, resident’s medication were mismanaged. This posed an immediate potential health, safety, and personal rights risks to residents in care.

Maintain cleanliness and prevent incontinence odors

5:00 PM87625(b)(3) Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence. This requirement is not met as evidence by:Based on observation and interviews It was observed a strong urine odor in resident room #24. Additionally, a mild urine odor was noted in resident room # 27. This posed a potential health, safety, and personal rights risks to residents in care.

Document each PRN medication dose taken

87465(c)(3) Incidental Medical and Dental Care(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN….(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.This requirement is not met as evidence by: Based on observation, medication review and interview (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered therefore, resident’s medication is not being administered per physician’s order. This posed an immediate potential health, safety, and personal rights risks to residents in care.

Maintain facility in clean, safe, sanitary condition

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times…This requirement was not met as evidence by: Based on observation and interviews the administrator did not ensure that resident’s shower was in good repair. This poses a potential health and safety to residents in care.

87224(a) Eviction Procedures(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5) …This requirement was not met as evidence by: Based on record review and interviews, R1 was evicted due to due to frequent non-emergency calls made through the pull cord system and the main office phone line. This poses a potential health and safety to residents in care.

Store centrally held medications in locked secure place

87465(h)(2). Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not met as evidenced by: Based on records reviewed, the licensee did not comply with the section cited above. The Department staff observed a spare key was kept on top of the medication cart in a pen container and was easily assessable to anyone in the lobby, such as residents, and or visitors. This poses an immediate health, safety or personal rights risk to persons in care.

Retain original records for at least three years

87506 Resident Records(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.This requirement is not met as evidence by: Based on observation, records review, and interviews, the Licensee did not retain resident R1's records as required which poses a potential health and safety risk to residents in care.

Maintain cleanliness and prevent incontinence odors

Based on observations the licensee did not comply with the section cited above. LPA Lee observed the back Terrence Building to have strong urine odor. LPA Lee observed 5 residents’ room to have a strong urine odor which poses an potential health, safety, or personal rights risk to persons in care.

Personal rights of residents in all facilities

Based on observations the licensee did not comply with the section cited above. LPA Lee observed the back Terrence Building to have strong urine odor. LPA Lee observed 5 residents’ room to have a strong urine odor which poses an immediate health, safety, or personal rights risk to persons in care.

Assist residents with self-administered medication

Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA Lee reviewed 5 resident MAR logs and 5 out of 5 logs was missing staff initials. LPA Lee also audit the medication and 2 out of 5 resident medications was either not given to resident or the medications are missing. This poses an immediate health, safety, or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...This requirement was not met as evidence by: Based on interviews, the Licensee did not ensure that the facility has an active administrator on the premises to provide adequate attention to manage the facility. This poses a potential health and safety to residents in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all the following personal rights: (2)To be accorded safe, healthful, and comfortable accommodations furnishings and equipment.This requirement was not met as evidence by: Based on observation and interviews the licensee did not ensure that resident’s rooms and bathrooms clean and sanitary for residents in care. This poses a potential health and safety to residents in care.

Clean linen quantity and hygiene supplies

87307(a)(3)(C) Personal Accommodations and Servicesa) Living accommodations and grounds shall be related to the facility's function…(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillowcases, mattress pads… This regulation was not met as evidence by:Based on observations and interview the licensee did not ensure that a provision of clean linens was available to each resident. Based on documentation two resident was observed with no sheets on their bed. This poses a potential risk to residents in care.

Care and supervision as defined by statute and rules

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) (f) and Health and Safety Code section 1569.2(i).This requirement is not met as evidenced by: Based on interviews and observations the licensee did not ensure care and supervision needs were provided. LPA Lee observed 15 residents in the common area with no facility present. This poses/posed an immediate health and safety risks to resident in care.

Maintain facility in clean, safe, sanitary condition

87303(a) Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times.This requirement is not met as evidenced by: Based on observation, interviews the licensee did not maintain the facility in a clean and sanitary condition. The facility currently has evidence of bedbugs. The kitchen is observed to be unclean and unsanitary. This poses a potential health and safety risk to residents in care.