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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201324
Report Date: 10/16/2024
Date Signed: 10/16/2024 03:47:46 PM

Document Has Been Signed on 10/16/2024 03:47 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 PLEASANTONFACILITY NUMBER:
019201324
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, DIANE DIEMFACILITY TYPE:
740
ADDRESS:5700 PLEASANT HILL ROADTELEPHONE:
(925) 416-0238
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: 103CENSUS: 86DATE:
10/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Ena Vilao, Business Office DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 10/16/2024, At 10:10 AM, Licensing Program Analysts (LPAs) Ardalan Gharachorloo and Lori Alexander arrived to conduct the investigation for the complaint received (No.15-AS-20240520111558). LPAs met with Ena Vilao, Business Office Director and explained the purpose of the visit. During the complaint visit, Licensing Program Analysts requested the resident' files, and were informed that they did not have access to those documents.

THE FOLLOWING DEFICIENCY WAS OBSERVED:

ยท At 1:30 pm LPAs requested the following documents: May 2024 shower schedule for residents, May 2024 toileting schedule for residents, Staff schedules for the month of May 2024, and home health records for R1, including but not limited the entire resident file for R1. These documents were not on file and were not available during visit.

The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 10/16/2024 03:47 PM - It Cannot Be Edited


Created By: Ardalan Gharachorloo On 10/16/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT PLEASANTON
FACILITY NUMBER: 019201324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/25/2024
Section Cited
CCR
87506(d)

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87506 Resident Records

(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement is not met as evidenced by:
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Administrator agree to submit requested documents to CCLD by POC due date.
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Based on file review, the licensee did not comply with the section cited above in by not having records available, staff schedule, laundry, shower, housekeeping schedules for residents for the month of May 2024 and the resident's file including but not limited for R1 which poses 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-Larios
LICENSING EVALUATOR NAME:Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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