IVY PARK AT SEVEN OAKS

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Deficient Practice Statement Based on interviews conducted, records review, and observation, R1’s Senna-Time medication bubble pack with quantity of 15 was first administered daily starting on 12/11/25 at 08:30AM. Bubble pack was checked and verified by Health Service Director and LPA, 8 tablets were administered with 7 tablets left in the bubble pack, which poses an immediate health and safety risk for the person in care.

Official plan of correction

POC Due Date: 12/17/2025 Plan of Correction Administrator stated will submit written POC of when all medication technicians will complete in-service training on medications by. POC will be submitted to Fresno CLL by 12/17/25. Staff rooster of in-service training completed will be submitted to the Fresno CCL.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303(a)(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: Deficient Practice Statement Based on observation, mold was observed in and around three of the kitchen floor sink drain and was observed dirty, which poses/posed a potential Health, Safety, and Personal Rights risk to the residents.

Official plan of correction

POC Due Date: 12/22/2025 Plan of Correction Kitchen floor sink drainers shall be clean and with no mold. Proof shall be submitted to Fresno CCL office by POC due date 12/22/25.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when LPA observed tools and box cutters in room 112, a cleaning bottle in room 107 bathroom cabinet, and small knives stored in room 213 kitchen drawers, unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2025 Plan of Correction Knives were immediately locked in room 213 cabinet. Staff removed tools from room 112, cleaning bottle from room 107. POC cleared during visit.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Deficient Practice Statement Based on records review and observation, R1’s medication Gabapentin 300 mg, R2’s medication Levothyroxine 100mcg, R2 medication Meloxicam 7.5 mg, R3 medication Divalproex 500 mg, and R3’s medication Vitamin D-3 2,000U were not administered as instructed by physician, which poses an immediate health and safety risk for the person in care.

Official plan of correction

POC Due Date: 01/16/2025 Plan of Correction Administrator agree to write statement of steps facility will take to ensure regulations is met. Statement will be submitted to Fresno CCL by POC due date 01/16/25. All assisted living medication techicians shall be retrained on medication training which will also include administering medications and review medications. Documentation of training topics with staff attendance rooster shall be submitted to the Fresno CCL office by 02/04/25.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by: Deficient Practice Statement Based on observation, hot water temperature in memory care unit measured at 130.3 degrees F in room 27, 125.3 degrees F in room 46, and 122.5 degrees F in room 12, which poses/ posed a potential health and safety risk for the person in care.

Official plan of correction

POC Due Date: 01/21/2025 Plan of Correction The facility shall maintain hot water temperature between 105 degree F and 120 degree F. The facility shall have a daily temperature log to ensure water temperature meets the regulation requirements. Daily temperature log with proof of hot water temperature is tested and maintained between 105 degree and 120 degree F shall be submitted to the Fresno CCL office by 01/21/25.

Official classification

Type B

Official code

87555(b)(21)

Regulation authority

CCR

What the official deficiency says

87555 (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement was not met as evidenced by: Deficient Practice Statement Based on interviews conducted, observation, and records reviewed, the facility walk in freezer was observed at 38 degrees F. Facility record show walk-in freezer temperature maintained between 2.4 and 34.9 degrees F, which posed/ poses a potential health and safety risk for the person in care.

Official plan of correction

POC Due Date: 01/21/2025 Plan of Correction Documentation the facility walk-in freezer temperature is maintained at 0 degrees or below shall be submitted to Fresno CCL office by POC due date 01/21/25.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed in room 112, medications on the kitchen counter, in bathroom, and in kitchen cabinet unlock. Medications were observed in room 105 in bathroom cabinet unlock. Medications were also observed unlock in kitchen cabinet in room 218. Medications were observed unlock and accessible to residents poses an immediate health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 01/24/2024 Plan of Correction Licensee shall ensure that all medications shall be locked and inaccessible to residents in care. Proof of medications removed and locked, inaccessible to residents shall be submitted to the department by POC due date 1/24/24.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed knives and cleaning chemicals unlock in resident room 105, 112, and 218 stored unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2024 Plan of Correction Licensee shall ensure that all sharps and chemicals shall be locked at all times and inaccessible to residents in care. Proof of sharps and chemicals removed and locked, inaccessible to residents shall be submitted to the department by POC due date 1/24/24.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465(a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview, R1 was administered R2’s medication by S1 which poses an immediate health and safety risks to persons in care.

Official plan of correction

S1 was retrained on administering medication on 07/20/23. LPA received copies of S1 in-service training and documentation. POC cleared during visit.

Deadline recorded: Jul 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87413(a)(2)

Regulation authority

CCR

What the official deficiency says

87413(a)(2) a) In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interview and record review, staff did not provide care and supervision when memory care R1 left the facility unsupervised on 07/10/23 at approximately 07:35PM. The facility was not aware R1 went AWOL until approximately at 07:47 PM when the facility was notified by the neighboring building that the resident was in their building lobby. This poses an immediate health and safety risks to persons in care.

Official plan of correction

Licensee shall submit a plan detailing steps the facility will take to ensure the requirements are met by 07/19/23. Licensee has agreed to submit AWOL in-service training and rooster of staff attendance to the Department by 08/01/23.

Deadline recorded: Jul 19, 2023. A deadline is not proof that correction was completed.