019201324-6-2-2026-15-AS-LFRO-DX2UAK-20260817152452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201324
Report Date: 06/02/2026
Date Signed: 06/02/2026 01:50:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/04/2025 and conducted by Evaluator Ardalan Gharachorloo

COMPLAINT CONTROL NUMBER: 15-AS-20251204162751

FACILITY NAME:	IVY PARK AT PLEASANTON		FACILITY NUMBER:	019201324
ADMINISTRATOR:	MARTINEZ, DIANE DIEM		FACILITY TYPE:	740
ADDRESS:	5700 PLEASANT HILL ROAD		TELEPHONE:	(925) 416-0238
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94588
CAPACITY:	103	CENSUS: 96	DATE:	06/02/2026
		UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Executive Director in training, Erica Glynn		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Due to neglect/ lack of supervision resulting in resident sustaining a fractured elbow

INVESTIGATION FINDINGS:

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On 06/02/2026 at 9:52 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to to deliver findings in regard to the allegation above.LPA met with Executive Director in training Erica Glynn and explained the purpose of the visit.

The Department conducted interviews and reviewed facility records, EMS records, and medical records regarding the allegation. Records revealed that on 11/18/2025, R1 was observed chasing an unknown staff person when R1 tripped and fell. EMS responded and assessed R1 following the fall. EMS records indicated R1 denied pain and did not exhibit signs of injury at that time. Records further indicated that R1's responsible party declined transportation to the hospital following the assessment.

***CONTINUE ON 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/04/2025 and conducted by Evaluator Ardalan Gharachorloo

COMPLAINT CONTROL NUMBER: 15-AS-20251204162751

FACILITY NAME:	IVY PARK AT PLEASANTON		FACILITY NUMBER:	019201324
ADMINISTRATOR:	MARTINEZ, DIANE DIEM		FACILITY TYPE:	740
ADDRESS:	5700 PLEASANT HILL ROAD		TELEPHONE:	(925) 416-0238
CITY:	PLEASANTON	STATE:CA	ZIP CODE:	94588
CAPACITY:	103	CENSUS: 96	DATE:	06/02/2026
		UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Executive Director in training Erika Glynn		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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On 06/02/2026 at 09:52 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegation above. LPA met Executive Director Executive Director in training, Erika Glynn and explained the purpose of the visit.

The Department conducted interviews and reviewed facility records, EMS records, and medical records regarding the allegation. Records reviews revealed that immediately following R1's fall on 11/18/2025, facility staff contacted emergency services. EMS responded to the facility and assessed R1. EMS records reviewed by the Department indicated that R1 denied pain, exhibited no injuries, and did not require emergency medical treatment. R1's responsible party declined transportation to the hospital following the EMS assessment.

CONTINUE ON 9099C***

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20251204162751

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PLEASANTON	FACILITY NUMBER: 019201324
	VISIT DATE: 06/02/2026

NARRATIVE

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***CONTINUE FROM 9099***

S1 informed the Department during an interview that R1 did not exhibit any signs or complaints of pain in her left arm following the reported fall and did not experience any additional falls between 11/19/2025 and 11/27/2025. S1 further stated that R1 was away from the facility with family for the Thanksgiving holiday from 11/27/2025 through 11/30/2025. Records reviewed indicated that on 11/30/2025, at approximately 8:50 a.m., R1 was admitted to an emergency room with complaints of left wrist pain related to an unspecified fall. Medical records documented a diagnosis of a nondisplaced fracture of the radial head (elbow fracture).

The Department interviewed S1 and S2, who reported that R1 remained at baseline following the incident, continued to ambulate independently, participated in normal daily activities, and did not complain of pain or discomfort. Records reviewed by the Department indicated that facility staff monitored R1 following the fall and documented R1's condition.

This agency has investigated the allegation above. We have found that the complaint was unfounded.
Exit interview conducted and a copy of this report was provided to the Executive Director.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20251204162751

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PLEASANTON	FACILITY NUMBER: 019201324
	VISIT DATE: 06/02/2026

NARRATIVE

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***CONTINUE FROM 9099***

The Department interviewed S1 and S2, who reported that R1 was ambulatory, independent with
walking, and was not considered a fall risk prior to the incident. S1 and S2 stated that following the
fall, R1 continued to ambulate throughout the facility, participated in activities, and did not complain
of pain or display signs of injury. Records reviewed by the Department showed that R1 left the
facility with family on 11/27/2025 and returned on 11/30/2025. Hospital records reviewed by the
Department revealed that on 11/30/2025, R1 was diagnosed with a nondisplaced fracture of the
radial head. However, the records did not identify when or where the injury occurred.

This agency has investigated the allegation. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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