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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 06/16/2026
Date Signed: 06/16/2026 02:45:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2026 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20260325150023
FACILITY NAME:IVY PARK AT ROCKVILLEFACILITY NUMBER:
486803653
ADMINISTRATOR:TEDRA GODFREYFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 356-2229
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 146DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Tedra Godfrey-AdministratorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff are not adequately trained
Staff mismanage resident medication
INVESTIGATION FINDINGS:
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At approximately 11:55 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegations and met with Administrator Tetra Godfrey.

On 03/25/2026 Community Care Licensing (CCL) received a complaint alleging that staff at Ivy Park “are not adequately trained” Complainant reports that, “staff appear inadequately trained, frequently fail to follow protocols” especially around the placement and use of a specialty device prescribed for R1.

LPA conducted witness, staff and resident interviews, obtained documents and evidence and made observations.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 21-AS-20260325150023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
VISIT DATE: 06/16/2026
NARRATIVE
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Continued from LIC9099

On 04/24/2026 LPA obtained a copy of a video of a specialty device system discarded in a garbage can and improperly set up per witness (1) W1. An interview with W1 indicates the speciality device was improperly set-up and discarded when staff could not facilitate proper use of the device. In addition, LPA obtain a photo on 05/21/2026 of the Resident end of the same device in a trash can and on 05/22/2026 LPA obtained a second photo of the collection side of the same device improperly set up. In an interview with staff member S3, S3 indicated that some of the staff applying the speciality device to R1 were “not trained” in use of R1’s specialty device, and that a private caregiver of R1 had written down the exact details of how to apply the device. An interview with staff member S1 indicates they had personally learned how to apply R1’s medical device from a hospice nurse not employed by Ivy Park, (rather than through an inservice provided at Ivy Park at Rockville) A similar interview with staff member S2, had S2 saying that the use of R1’s medical device was a particularly private and invasive procedure and as such would not have be acted out or demonstrated with new staff in front of R1. When S2 was asked, “Does your team (at Ivy Park) have written step-by-step instructions on how to apply the specialty device to R1 or how to help R1 use their CPAP and if the trainings were documented", S2 offered, “It is not something we typically see a lot of, again it would be shadow training or R1’s private caregiver explaining how it is done. The training is not documented”

Because photos and a video obtained by this LPA demonstrate the improper set-up of R1’s medical device and because no evidence of staff documented training in the application or use of the speciality device could be obtained at the time of the investigation, the preponderance of evidence standard has been met, therefore the above allegation of “staff are not adequately trained” is found to be SUBSTANTIATED.

A type B citation for violation of CCR 87468.2(a)(4) which requires caregivers to be competent in the care they provide is being sited. See 9099-D page.

In addition, on 03/25/2026 CCL received a complaint alleging that staff at Ivy Park at Rockville failed to ensure PRN and prescribed medicines were dosed and administered properly. An interview with R1 revealed that they had long received the incorrect dose of their prescribed medicine and once the dosage was corrected, a long term health concern of theirs improved.

Continued on LIC9099-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 21-AS-20260325150023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
VISIT DATE: 06/16/2026
NARRATIVE
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Continued from LIC9099-C

A subsequent interview with W1, indicates W1 raised the medicine administrator error to the Management at Ivy Park with W1 indicating that it was not until W1 raised the administration error, that the dosage was corrected. W1 also noted that a long term health issue of R1 appeared to improve after the correction. In addition, an interview with S1, had S1 recalling having to attend and In-service on the proper administration of the medicine in question after the error was discovered. A subsequent interview with S3, had S3 indicating knowledge of the medicine error and noting that they to, felt the correction in the error resulted in some improvement of R1’s long term health condition. Finally, because R1’s Service Plan indicates needing, “Maximum Assistance” with Medication Management, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A type A citation for CCR 87465(a)(4) is being assessed (see LIC9099-D) page

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due dates, may result in a civil penalty assessment.

Exit interview conducted. Copy of report discussed and provided to Administrator Tedra Godfrey.

A copy of Appeal Rights were left.

Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 21-AS-20260325150023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/26/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in... Facilities:(a) in addition to... Section 87468.1...residents...shall...have the
following Personal Rights: (4) To care, supervision, and services that meet their...needs and delivered by staff that are sufficient in numbers.
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Licensee to submit self-certification that all staff who administer medical devices for R1 and other residents with similar devices have had hands-on training sufficienct to ensure proper application of devices like PureWick Incontinence devices, CPAP devices etc.
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This requirement was not met as evidence by:
Based on, interviews and record review licensee did not comply with section cited above in ensuring that training in use of R1's medical device was performed by all staff administering R1s medical device.
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A list of staff that will apply medical devices such as PureWick and CPAP devices, what was learned, the steps that staff will use to apply these specific device, as well as, the hands-on training they have recevied will be submitted to CCL by 06/26/2026
Request Denied
Type A
06/18/2026
Section Cited
CCR
87465(a)(4)
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87465(a)(4) The Licensee shall assist Residents with self-administered medications as needed:

This requirement is not met as evidence by:
Based on record review and interviews
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Licensee to submit self-certification that R1 is now receiving a proper dose of their prescribed medications. Licensee to also submit the specific steps staff will take in measuring out Miralax specfically for R1, as well as all prescribed medications for Residents in general by by 06/18/2026
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The licensee did not comply with the section cited above. Licensee did not ensure that Resident 1 (R1) recieved a proper dose of ther Miralax per Physicians orders, which poses and immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2026 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20260325150023

FACILITY NAME:IVY PARK AT ROCKVILLEFACILITY NUMBER:
486803653
ADMINISTRATOR:TEDRA GODFREYFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 356-2229
CITY:FAIRFIELDSTATE:CAZIP CODE:
94534
CAPACITY:199CENSUS: 148DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Tedra Godfrey-AdministratorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff do not respond to resident's calls for assistance in a timely manner
Staff do not keep facility clean or sanitary
Staff do not safeguard resident's personal care items
Staff do not adequately meet resident's hygiene needs
INVESTIGATION FINDINGS:
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At approximately 11:55 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegations and met with Administrator Tetra Godfrey.

On 03/25/2026 Community Care Licensing (CCL) received a complaint alleging that, “staff do not respond to resident’s call for assistance in a timely manner”. A subsequent interview with complainant offered that under the old management company the wait times were long, but that wait times had improved and were no longer a problem with the newer management company. Additional interviews with R3 and R5 indicated no concern for the call light waiting times. During this LPAs visit with R1, R1’s call light was pressed and a staff member showed up in 5 minutes. An interview with R1 had R1 indicating that at times the call light did take too long for them, but at other times the response was quick. An interview with S2 had S2 saying they felt the facility was better staffed under a new management company and that they understood call lights were to be answered within 10 minutes.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 21-AS-20260325150023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
VISIT DATE: 06/16/2026
NARRATIVE
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Continued from LIC9099-A
A review of the call light record revealed that out of 90 calls for service on the AM shift of 03/23/26, call light response time took an average of 8 minutes and 48 seconds.

Because Complainant reports that call light response time is no longer a primary concern and because of conflicting information about call light response times, this allegation is Unsubstantiated

In addition, on 03/25/2026 CCL received a complaint alleging that staff at Ivy Park at “Do not keep the facility clean or sanitary”. Upon LPAs entry into the facility 04/01/2026 and again on 04/20/2026 I observed the facility to be clean, and without odors, in addition I observed multiple housekeepers cleaning and rolling well stocked cleaning carts throughout the property. On 04/20/2026 upon my unannounced entry into R1’s room, I again observed R1’s room to be clean and without odors and observed no troubling signs of improperly stored or disheveled personal medical devices. When R1 was asked if they had help to clean their room, R1 replied, “They (staff) do everything, they vacuum, change my bedding, wipe down things”. Similarly, when R2 was asked about housekeeping, R2 replied, “they will clean my room, vacuum, wash my clothes, sink and bathroom floor”, while R3 indicated, “The housekeeper, they come and do everything, they clean the linen, oh, they do everything!”. This LPA did receive a photo of a personal medical device being partially discarded or stored in a waste basket, but due to conflicting information about whether staff keep the facility clean or sanitary or not, this allegation is unsubstantiated

Additionally, on 03/25/2026 CCL received a complaint alleging that, “Staff do not safeguard residents’ personal items”. The detail of the complaint reads, “The physician ordered a medical device for the resident, but the equipment repeatedly goes missing, leading the complainant to believe staff may be misusing or taking the supplies of the the specialty item.” An interview with R1 had R1 saying, that while at first it was thought that the stocks of the medical device were going missing, they were being stored by the Med-Techs.

An interview with W1 raised uncertainty about where addition supplies of R1’s medical device were going and that W1 did not think they were being thrown away, but that a decision was made that supplies of the device would be stored and locked up by the Med-Tech staff.

Continued on LIC9099-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 21-AS-20260325150023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
VISIT DATE: 06/16/2026
NARRATIVE
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Continued from LIC9099-C

An interview with S3 indicated that the facility decided that the Med-Techs would both store and apply the device when R1’s private caregiver was not available to do so. In addition, an interview with R5 whose spouse uses a similar device reported no being concerned for the loss or storage of a similar device.

Because conflicting information was received about the deposition of R1’s specialty medical device and because the facility developed a strategy to safeguard the specialty devices of R1, the complaint that “Staff do not safeguard resident’s personal care items is Unsubstantiated.

Finally, on 03/25/2026 CCL received a complaint alleging that, “Staff do not adequately meet resident’s hygiene needs”. The detail of the complaint reads, “staff do not follow written or verbal care instructions, contributing to ongoing issues such as recurrent Urinary Tract Infection (UTIs) that the resident’s (R1) physician suspects may stem from improper cleaning after bowel movements”

This LPA notes that R1 has the weekly help of a private caregiver and R1’s Service Planned signed by R1 on 11/23/2025 indicates R1 receives no help from staff at Ivy Park at Rockville for showering/bathing or grooming but R1 does require moderate assistance with transfers and maximum assistance with toileting needs from Ivy Park staff.

LPA does not have physician notes that speculate on the recurrence of UTIs that may stem from improper cleaning after bowel movements.

An interview with complainant had complainant speculating that R1 may have had as many as four (4) UTIs, over the last 10 months since a new management company took over at Ivy Park at Rockville, but complainant also offered that R1 had a severe UTI requiring hospitalization, before a new management company took over 10 months ago.


Because of conflicting information about whether staff do, or do not adequately meet resident’ hygiene needs, the complaint that “Staff do not adequately meet resident’s hygiene needs” is Unsubstantiated.

Continued on LIC9099-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 21-AS-20260325150023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
VISIT DATE: 06/16/2026
NARRATIVE
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Continued from LIC9099-C
A finding that the complaint allegations are Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Administrator Tedra Godfrey
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8