019200722-8-29-2024-15-AS-YFLS-DC2VFL-20241217152407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200722
Report Date: 08/29/2024
Date Signed: 08/29/2024 02:21:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240627140346

FACILITY NAME:	IVY PARK AT PLEASANTON		FACILITY NUMBER:	019200722
ADMINISTRATOR:	TRACY BURKE		FACILITY TYPE:	740
ADDRESS:	5700 PLEASANT HILL RD		TELEPHONE:	(925) 416-0238
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94588
CAPACITY:	103	CENSUS: 84	DATE:	08/29/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Elaine Wong, Regional Director of Operations		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff neglect led to resident sustaining pressure injury
Staff left resident unattended in a dirty, soaking wet diaper for extended periods
Staff did not treat resident with respect

INVESTIGATION FINDINGS:

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On 8/29/24 at 12:45 p.m., Licensing Program Analyst (LPAs) Greg Clark and Ardalan Gharchorloo arrived unannounced to deliver findings in regard to the allegations above. LPAs met with Elaine Wong, Regional Director of Operations and explained the purpose of the visit.

During the course of the investigation LPAs interviewed the reporting party (RP), S1 and S2. LPAs also reviewed R1’s file and performed a collateral visit to the facility that R1 was discharged to (F1).

R1 was admitted to the facility on 6/03/2024 and discharged to F1 on 6/29/24. R1 was bedridden at time of admission.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240627140346

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT PLEASANTON	FACILITY NUMBER: 019200722
	VISIT DATE: 08/29/2024

NARRATIVE

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***report continues from LIC9099***

Allegation: Staff neglect led to resident sustaining pressure injury.

Review of documents in R1’s file at this facility and at F1 revealed that R1 did not have any pressure injuries. S1 and S2 also stated that R1 did not have any pressure injuries and that her skin was “in good shape” except for a little redness under R1’s breasts and in her groin area. This allegation is unsubstantiated.

Allegation: Staff left resident unattended in a dirty, soaking wet diaper for extended periods.

The RP stated that she heard about R1 being left in a dirty diaper from the private caretaker the RP hired to stay with R1. The RP did not have any further details about how often this occurred or how long R1 went between diaper changes. S1 and S2 stated that they never received any complaints from any of R1’s care team (private caretaker, home health nurses and facility staff) about the care R1 was receiving at the facility. Staff further stated that all residents who are bedridden are placed on a routine schedule for diaper changes and are changed as need in between the scheduled times. This allegation is unsubstantiated.
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Allegation: Staff did not treat resident with respect.

The RP stated that a facility staff told R1’s private caregiver that R1 “shouldn’t be here at the assisted living facility.” The RP further stated that she was not sure if R1 even heard the statement. S1 and S2 stated that they felt R1 was appropriately placed at the facility and never heard any staff stated anything to contrary. This allegation is unsubstantiated.

This agency has investigated the complaints alleging staff neglect led to resident sustaining pressure injury, staff left resident unattended in a dirty, soaking wet diaper for extended periods and staff did not treat resident with respect. We have found that the complaints were unsubstantiated. 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, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC9099 (FAS) - (06/04)

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