Inspection Reports for Ivy Park at Roseville

A case management visit was conducted regarding two separate incident reports received on August 6, 2025 and August 22, 2025 concerning medication errors.

The visit found that medication was given incorrectly to two residents and medication was given to the wrong resident, posing a potential health and safety risk. A Type B deficiency was cited related to failure to assist residents with self-administered medications as required.

The visit was complaint-related, triggered by two incident reports regarding medication errors received on August 6 and August 22, 2025.

Unannounced complaint investigation visit conducted due to multiple allegations including staff causing injuries during transfers and failure to meet residents' needs.

The investigation substantiated one allegation that a resident sustained an injury during transfer. Several other allegations related to timely response, incontinence care, room maintenance, hygiene, medical attention, laundry services, staff training, appointment attendance, and incident reporting were found to be unsubstantiated or unfounded.

The complaint investigation was substantiated for the allegation that staff caused injuries to a resident during transfers. Other allegations including failure to timely respond to resident alerts, meet incontinence needs, maintain resident rooms, meet hygiene needs, timely seek medical attention, provide appropriate laundry services, staff training, ensuring attendance at scheduled appointments, and proper incident reporting were unsubstantiated or unfounded.

The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with health and safety regulations.

The facility was found to be clean, safe, sanitary, and in good condition with no deficiencies observed. Staff training and resident medication orders were reviewed and found compliant.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was retaining a resident with a higher level of care needed and that staff do not ensure resident's call button is answered in a timely manner.

The investigation found that although one resident required a 2-person assist and more extensive care, the facility was still able to meet the resident's needs, and the allegation was unfounded. Regarding the call button response times, the average response was approximately 10 minutes, and the allegation was unsubstantiated due to insufficient evidence.

Two allegations were investigated: 1) Facility retaining a resident with a higher level of care needed, which was found to be unfounded. 2) Staff not ensuring resident's call button is answered timely, which was found to be unsubstantiated.

The inspection was an unannounced case management visit to review two separate incident reports received from the facility.

The Licensing Program Analyst interviewed the administrator and reviewed documentation, finding that the facility followed proper protocol and regulation on each incident. No deficiencies were cited during the inspection.

Unannounced complaint investigation visit triggered by allegations that staff did not provide adequate supervision resulting in a resident wandering away from the facility unsupervised, and that the facility front door alarm was not working.

The investigation substantiated both allegations: staff failed to adequately supervise a resident who wandered outside the facility, and the wanderguard alarm system was not properly functioning due to sensor settings and placement issues. The facility has since updated the wanderguard system and implemented weekly checks.

The complaint was substantiated. Allegations included inadequate supervision leading to a resident wandering unsupervised outside the facility and failure to ensure the front door alarm was working. Investigation included interviews and record reviews confirming these issues.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-02 regarding inadequate monitoring of residents for early signs of illness and failure to follow infection control requirements.

The investigation substantiated that staff did not ensure residents were monitored for early signs of illness and failed to follow infection control requirements, including a staff member entering a resident's room without proper PPE. Another allegation regarding insufficient care and supervision was found to be unfounded.

The complaint investigation was substantiated based on evidence that staff did not monitor residents for early signs of illness and did not follow infection control requirements, including PPE usage. One allegation regarding insufficient care was found to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not abiding by the admissions agreement and that staff were not allowing residents to have visitors.

The investigation found both allegations to be unfounded. The facility's admission agreement allows for fees related to room service and guest meals, and visitors are allowed during business hours with restrictions on overnight stays requiring prior approval.

The complaint investigation addressed two allegations: 1) Facility not abiding by the admissions agreement regarding charges for meals delivered to resident rooms, and 2) Facility staff not allowing residents to have visitors. Both allegations were found to be unfounded after review of documents and interviews.

The inspection was an unannounced annual inspection conducted to ensure the health and safety of residents in care at the facility.

No deficiencies were observed during the inspection. The facility was found to have adequate food supply, proper medication storage, complete first aid kit, and staff records indicating required clearances and training.

Unannounced complaint investigation visit conducted due to multiple allegations received on 2023-11-08 regarding facility hazards, medication administration, mold presence, meal replacement requests, facility repairs, disrepair, and dietary plan adherence.

Most allegations were found to be unsubstantiated or unfounded after interviews, file reviews, and facility tours, except for the allegation that facility staff did not follow a resident's dietary plan, which was substantiated due to serving melon to an allergic resident and lack of allergy documentation in the kitchen.

Complaint investigation involved multiple allegations including hazardous conditions leading to resident fall, medication administration errors, mold presence, meal replacement refusals, untimely facility repairs, facility disrepair, and failure to follow resident dietary plan. All allegations except the dietary plan violation were found unsubstantiated or unfounded. The dietary plan allegation was substantiated due to serving allergenic food and lack of proper allergy documentation.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-10-06 regarding insect infestation and overcharging a resident.

The allegation that staff did not keep the facility free of insects was found unsubstantiated after inspection and interviews. The allegation that the facility was overcharging a resident was found unfounded after review of billing statements and confirmation of a proper rental increase notice.

Two allegations were investigated: 1) Staff did not keep facility free of insects, which was unsubstantiated. 2) Facility is overcharging a resident in care, which was unfounded after review of billing and rental increase documentation.

Unannounced visit to investigate complaints alleging that facility staff is not ensuring the kitchen is kept in a sanitary condition and that the facility did not issue a refund to a resident in care.

The investigation found the kitchen to be clean and sanitary, resulting in the first allegation being unfounded. The second allegation regarding failure to issue a refund was found to be unsubstantiated as the facility refunded the resident for unauthorized charges.

Two complaints were investigated: 1) Facility staff not maintaining kitchen sanitation, found to be unfounded. 2) Facility did not issue a refund to a resident, found to be unsubstantiated after confirmation of refund issuance.

The inspection was conducted as a pre-licensing visit for a change in ownership (CHOW) of the facility currently licensed as Sierra Pointe.

The facility met all pre-licensing components including proper furnishing and maintenance of resident bedrooms, clean and sanitary bathrooms, adequate food supply, operational smoke and carbon monoxide detectors, functional fire extinguisher, presence of grab bars, unobstructed exits, and secure storage of toxins, medications, and sharps. The disaster drill was current and the administrator holds a valid certificate.