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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 05/14/2024
Date Signed: 05/14/2024 02:53:13 PM


Document Has Been Signed on 05/14/2024 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OAKLAND HILLSFACILITY NUMBER:
019200755
ADMINISTRATOR:CAGULADA, DILLON RFACILITY TYPE:
740
ADDRESS:11889 SKYLINE BLVDTELEPHONE:
(510) 531-7190
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:100CENSUS: 61DATE:
05/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jessica Pryor, Regional Operations SpecialistTIME COMPLETED:
03:05 PM
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On 5/14/2024 at 1:45 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Jessica Pryor, Regional Operations Specialist.

CCLD received an incident report stating that a resident was not given a medication that was prescribed to them. LPA spoke with S1 who stated that R1's daughter noticed that the medication Aricept was not on her mothers medication list. S1 stated that they did an internal investigation where they found that R1 was originally prescribed 5mg of Aricept for four weeks and to increase to10 mg after that. The facility completed the first four weeks but did not increase to 10 mg after that. It was noticed on April 11, 2024 that the pharmacy never sent the new dosage.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/14/2024 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 OAKLAND HILLS
FACILITY NUMBER: 019200755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by
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The facility agrees to review the process for new or changing medications for the residents. Proof of Correction will be submitted to CCLD by POC date.
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Based on record review and inspection of medications, the licensee failed to ensure medications are administered as prescribed. R1's medication change was not dispensed. This pose immediate health risks to resident 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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