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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:20:05 PM

Substantiated


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
12/14/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20231214100044
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: 77DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jourdan Olivier-Verde, Activity DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff locks residents room.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver findings on the above allegations. LPA met with Activity Director, Jourdan Olivier-Verde and explained the purpose of visit. Interim Executive Director was not available at the moment. LPA got confirmation for Jourdan to sign the report.
During the course of investigation, LPA interviewed S1, S2, and S3 stated Evergreen (memory care unit) residents’ room are being lock.
Based on interviews conducted, S2 and S3 stated resident have to call for care staff or housekeeper to let them in. Residents are not being able to freely enter their own room.
Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22 are cited on the attached LIC 9099D.
Exit interview was conducted with Activity Director, Jourdan Olivier-Verde and Appeal Rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 2
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20231214100044
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
03/21/2024
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities

This requirement is not met as evidenced by:
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Licensee agree to have all memory care residents room to be unlock, and sent in self-certiified letter stating that Licensee understand resident personal rights by the POC date.
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Based on interviews conducted,S1, S2, and S3 states that residents room are being locked and cannot freely go in and out of their room.
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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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2