019200755-8-20-2024-15-AS-KHOS-D8HJ54-20240826064406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:02:17 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
08/15/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240815104509

FACILITY NAME:	IVY PARK AT OAKLAND HILLS		FACILITY NUMBER:	019200755
ADMINISTRATOR:	YOLANDA HARRELL		FACILITY TYPE:	740
ADDRESS:	11889 SKYLINE BLVD		TELEPHONE:	(510) 531-7190
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94619
CAPACITY:	100	CENSUS: 60	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Yolanda Harrell, Executive Director (ED)		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not follow physician's orders

INVESTIGATION FINDINGS:

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On 08/20/24 at 12PM, Licensing Program Analysts (LPAs) A Gharachorloo and D Panlilio conducted a subsequent complaint visit, met with executive director (ED), gathered information and delivered investigation finding of above allegation. LPAs explained the purpose of the visit with LC.

During investigation, the department obtained the following documents from ED:
Admission Agreements,Personnel Records, Resident's roster, Pre-placement appraisal, Fact sheet, ID emergency contact information, needs and services plans/reappraisal, Physician's Reports, Doctor's Orders, meal schedules/special diets,centrally stored medications & medication administration records (MARs) and incident reports. Continued on the next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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-20240815104509

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 OAKLAND HILLS	FACILITY NUMBER: 019200755
	VISIT DATE: 08/20/2024

NARRATIVE

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Allegation: Staff did not follow physician's orders
Investigation Finding: Unsubstantiated
During investigation, LPA A Gharachorloo interviewed staff (ED, S1,S2,S3) who confirmed with LPA that resident (R1) is given daily special diet meals as prescribed by his primary care physician (PCP). LPA observed kitchen staff posted on their bulletin board all residents' monthly special diet meals. Staff demonstrated with LPA how they prepared each resident's special diet meals during visit. Review of R1's needs & services plan showed his special diet requirements were followed by staff daily. Based on the department’s observations and interviews which were conducted and record review(s), we have found that although the allegation that staff did not follow physician's orders may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies cited during visit.

Exit interview conducted and copy of this report provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

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