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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 06/28/2024
Date Signed: 06/28/2024 01:41:06 PM


Document Has Been Signed on 06/28/2024 01:41 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
OAKLAND ASC, 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: 62DATE:
06/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director, Yolanda HarrellTIME COMPLETED:
02:00 PM
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On 6/28/2024 at 10:30AM LPA A Gomez arrived to conduct a case management as a result of an unusual incident report received on 6/22/2024. LPA met with Executive Director, Yolanda Harrell and explained the purpose of the visit.
It was reported that on 6/21/224 S1 took R1 from the facility without concent to the store where R1 purchased DaQuil medication. R1 has dementia and is on a medication program. According to the unusual incident report " On 6/22/2024 at approximately 1745hrs wellness nurse S2 notified RHSS that S1 had taken R1 to the neighborhood store to purchase DayQuil medication. R1 is currently on the medication program and has a diagnosis of dementia. R1 opened the bottle and ingested an unknown amount. S1 did not have i the permission of the community or family to take R1 to the store." Physicians and responsible parties were notified of the incident.; Resident was monitored for any effects. S1 was placed on suspension but has since returned to the facility.

LPA reviewed and obtained copies of R1's care plan and physicians report. R1 is not allowed to manage their own medications. LPA also reviewed and obtained copies of S1's personnel file including all completed training records. LPA interviewed S1 in regard to their training's and understanding of care of residents with dementia.

At this time LPA is issuing 2 type A deficiencies in relation to this incident.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2024 01:41 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
OAKLAND ASC, 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: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87411(a)

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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ... for the provision of adequate services.

This requirement was not met as evidence by:
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By POC date Executive director agrees to develop training plan for staff to include on the job evaluations
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Based on interview and incident report staff was not competent on the subject matter of residents with dementia and the process for residents leaving the facility which could pose a potential health and safety 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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2024 01:41 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
OAKLAND ASC, 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: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2024
Section Cited
CCR
87705(f)(2)

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(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, ... and disinfectants.

This requirement was not met as evidence by:
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Medication has been removed from R1.
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Based on interview and incident report staff allowed R1 to have unsupervised access to over-the-counter medication which posed an immediate health and safety 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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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