Inspection Reports for
The Ivy at Blue Oaks
275 Roseville Parkway, Roseville, CA 95678, Roseville, CA, 95678
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
66% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Capacity: 157
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was conducted as a case management visit while delivering complaint findings related to an incident where a resident (R1) left the facility unassisted on 12/14/2025.
Complaint Details
The visit was complaint-related due to an incident report of resident R1 leaving the facility unassisted. The complaint findings were delivered during the visit. The resident returned unharmed approximately 50 minutes later. Staff failed to respond properly to wander-guard alerts and exit alarms. The complaint was substantiated by the cited deficiencies.
Findings
The investigation found that although there were sufficient staff, they did not competently monitor the resident or respond to exit alarms, allowing the resident to leave undetected. Deficiencies were cited for failure to have competent staff monitoring and responding to alarms, posing immediate and potential health and safety risks.
Deficiencies (1)
Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on records and interviews. This posed an immediate risk to R1.
Report Facts
Facility capacity: 157
Deficiency count: 1
Plan of Correction due date: Dec 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Michelle Swearingen | Administrator/Director | Facility administrator met during the inspection |
| Maribeth Senty | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 157
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was a case management visit conducted while delivering complaint findings related to an incident where a resident (R1) left the facility unassisted on 2025-12-14.
Complaint Details
The visit was complaint-related due to an incident report of resident R1 leaving the facility unassisted. The resident returned unharmed. The complaint was substantiated with findings of staff failure to monitor and respond to alarms properly.
Findings
The investigation found that staff did not competently monitor the resident or respond to exit alarms due to multiple factors including busy front desk staff, lack of pager alerts, and poor communication. Deficiencies were cited for personnel requirements posing immediate and potential health and safety risks.
Deficiencies (1)
Personnel Requirements - General: Facility personnel were not sufficient in numbers and competent to provide necessary services, posing an immediate risk to resident R1.
Report Facts
Facility Capacity: 157
Deficiency Count: 1
Plan of Correction Due Date: Dec 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Michelle Swearingen | Administrator/Director | Facility administrator met during the inspection and involved in the incident discussion |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 157
Deficiencies: 0
Date: Dec 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff threatened a resident in care.
Complaint Details
The allegation was that facility staff threatened a resident in care. Interviews with the resident, staff, and administrator did not support the allegation. The complaint was found to be unsubstantiated.
Findings
The Licensing Program Analyst conducted extensive interviews and was unable to find a preponderance of evidence to substantiate the allegation. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Michelle Swearingen | Administrator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Capacity: 157
Deficiencies: 0
Date: Dec 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff threatened a resident in care.
Complaint Details
The complaint alleged that facility staff threatened a resident. After investigation, the allegation was found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation included extensive interviews with the resident, staff, and administrator. The Licensing Program Analyst was unable to find a preponderance of evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Report Facts
Facility capacity: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Michelle Swearingen | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 157
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not respond to a resident call for assistance due to insufficient staffing and did not provide identified care assistance to the resident.
Complaint Details
The complaint was substantiated based on evidence that staff did not respond timely to a resident's call for assistance due to insufficient staffing and failed to provide care as identified in the resident's service plan. The investigation included review of call button records, interviews with staff and the resident's spouse, and review of resident care plans.
Findings
The investigation found the allegations substantiated. Records and staff statements confirmed that on 8/28/25, a resident (R1) experienced a medical emergency and staff response was delayed due to insufficient staffing and unreliable communication devices. Additionally, personal assistance and care identified in R1's service plan were not consistently provided following a change in condition, posing a potential risk to the resident.
Deficiencies (2)
Personnel Requirements - General: Facility personnel were not sufficient in numbers to meet resident needs, posing a potential risk to R1.
Basic Services: Personal assistance and care as needed by the resident and as indicated were not provided following a change in condition, posing a potential risk to R1.
Report Facts
Capacity: 157
Census: 104
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Michelle Swearingen | Executive Director/Administrator | Facility administrator met with during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 157
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations that facility staff did not respond to a resident call for assistance due to insufficient staffing and did not provide identified care assistance to the resident.
Complaint Details
The complaint was substantiated based on evidence including resident records, staff interviews, and call button records. The complaint involved failure to respond to resident calls and failure to provide agreed care assistance. The substantiation means the allegation was valid by the preponderance of evidence standard.
Findings
The investigation found the allegations substantiated. Staff shortages and unreliable communication devices delayed response to a resident's medical emergency. Personal assistance and care identified in the resident's service plan were not consistently provided, posing a potential health and safety risk.
Deficiencies (2)
Personnel Requirements - Facility personnel were not sufficient in numbers to meet resident needs, posing a potential risk to the resident.
Basic Services - Personal assistance and care as needed by the resident were not provided as indicated, posing a potential risk to the resident.
Report Facts
Capacity: 157
Census: 104
Deficiency count: 2
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Michelle Swearingen | Executive Director/Administrator | Facility administrator met with evaluator and was involved in investigation |
Inspection Report
Annual Inspection
Capacity: 157
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
The inspection was conducted as a required unannounced annual inspection to evaluate the facility's compliance using the CARE tool.
Findings
The Licensing Program Analyst toured the facility and reviewed resident and staff files, finding no immediate health or safety concerns and no deficiencies cited during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Swearingen | Executive Director | Met with Licensing Program Analyst during inspection. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the annual inspection. |
| Maribeth Senty | Licensing Program Manager | Named in report header. |
Inspection Report
Annual Inspection
Capacity: 157
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
The inspection was a required, unannounced annual inspection conducted to evaluate the facility's compliance using the CARE tool.
Findings
The Licensing Program Analyst toured the facility and reviewed resident and staff files, finding no immediate health or safety concerns and no deficiencies cited during the inspection.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the annual inspection and met with the Executive Director |
| Michelle Swearingen | Administrator/Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Capacity: 157
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-06-27 regarding staffing adequacy, staff behavior, and training at the facility.
Complaint Details
The complaint was unsubstantiated. Allegations included insufficient staffing to meet residents' hygiene needs, rough handling of residents, staff yelling at residents, and inadequate staff training. The Licensing Program Analyst found no evidence to support these claims after records review and interviews.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staffing shortages were alleged to have occurred months prior but specific incidents were not substantiated. No evidence supported claims of rough handling or yelling by staff, and training deficiencies were not identified.
Report Facts
Facility capacity: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation visit and findings |
| Michelle Swearingen | Administrator | Met with the Licensing Program Analyst during the investigation |
| Maribeth Senty | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 103
Capacity: 157
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The inspection was a case management visit conducted to discuss the progression of a resident's increased aggressive behaviors and efforts to mitigate these behaviors, including review of an eviction notice received for the resident.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst observed the resident visiting with friends and discussed behavior management strategies with the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Swearingen | Administrator/Director | Met with Licensing Program Analyst during case management visit and discussed resident behavior. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 103
Capacity: 157
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The inspection was a case management visit conducted to review the situation regarding a resident (R1) who had received an eviction notice due to aggressive behavioral expressions.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst observed the resident visiting with friends and discussed with the Executive Director the progression of the resident's behaviors and mitigation efforts.
Report Facts
Capacity: 157
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit |
| Michelle Swearingen | Administrator/Executive Director | Met with Licensing Program Analyst during the visit and discussed resident behavior |
Inspection Report
Original Licensing
Census: 71
Capacity: 157
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The inspection was a post-licensing visit conducted to evaluate the facility using the CARE tool and ensure compliance with updated regulations effective 1/1/25.
Findings
The facility was toured including interior and exterior areas with no immediate health or safety concerns observed. Resident and staff files were reviewed and found complete and well organized. No deficiencies were cited during this inspection.
Report Facts
Resident files reviewed: 3
Staff files reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the post-licensing inspection |
| Michelle Swearingen | Administrator/Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 157
Deficiencies: 1
Date: Feb 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-02-06 regarding staff not following refund conditions at the facility.
Complaint Details
The complaint was substantiated. The allegation involved failure to follow refund conditions related to a preadmission fee paid by resident R1 in July 2024. The refund was delayed due to clerical errors and personnel changes. The refund was ultimately issued and verified by 2025-02-14.
Findings
The investigation substantiated the complaint that the facility failed to refund a preadmission fee timely due to clerical errors, including mailing the refund check to an incorrect person. The issue was resolved with the resident receiving the refund by 2025-02-14.
Deficiencies (1)
Admission agreements did not meet refund conditions requiring a 100 percent refund of preadmission fees if the applicant decides not to enter the facility prior to completing a preadmission appraisal, posing a potential risk to resident personal rights.
Report Facts
Capacity: 157
Census: 64
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
| Cheryl Stevenson | Executive Director / Acting Administrator | Facility representative involved in investigation and report review |
| Angelique Doyle | Administrator | Named as facility administrator |
Inspection Report
Original Licensing
Capacity: 157
Deficiencies: 0
Date: Nov 20, 2024
Visit Reason
The inspection visit was conducted as a pre-licensing evaluation to assess the facility's readiness for licensing approval.
Findings
The Licensing Program Analyst toured the facility and found no immediate health or safety concerns. The facility is in significant compliance, with the license pending approval.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the pre-licensing inspection and met with the Executive Director. |
| Angelique Doyle | Administrator/Director | Met with the Licensing Program Analyst during the inspection. |
Report
September 23, 2025
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