019201329-9-5-2025-15-AS-YFLS-DLTPSX-20250924113505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201329
Report Date: 09/05/2025
Date Signed: 09/05/2025 12:53:08 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
06/10/2025 and conducted by Evaluator Ardalan Gharachorloo

COMPLAINT CONTROL NUMBER: 15-AS-20250610101445

FACILITY NAME:	IVY PARK AT OAKLAND HILLS		FACILITY NUMBER:	019201329
ADMINISTRATOR:	HARRELL, YOLANDA		FACILITY TYPE:	740
ADDRESS:	11889 SKYLINE BOULEVARD		TELEPHONE:	(510) 531-7190
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94619
CAPACITY:	100	CENSUS: 85	DATE:	09/05/2025
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Yolanda Harrell, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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The facility did not notify the responsible party in a timely manner.
Staff does not meet training requirement.

INVESTIGATION FINDINGS:

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On 09/05/2025 at 9:55 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to continue the investigation and deliver findings regarding above allegations.LPA met with Executive Director, Yolanda Harrell who arrived at the facility at 11:05 AM, and explained the purpose of the visit.

During the course of the investigation,LPA conducted interviews with 4 staff (S1-S4) and 3 residents (R1-R3), obtained the staff and resident roster, and gathered documents related to R1's care as well as hospice file, internal incident reports, communication logs and charting notes. LPA also reviewed 3 staff files and toured R1's room.

Allegation: The facility did not notify the responsible party in a timely manner - Unsubstantiated

W1 reported, “I should have been notified immediately. There was no communication for at least an hour after the fall.” LPA interviewed S1 who stated, “When an emergency occurs, caregivers notify the med tech and unit lead, and they assess the situation almost immediately.

***CONTINUE ON 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

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-20250610101445

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 OAKLAND HILLS	FACILITY NUMBER: 019201329
	VISIT DATE: 09/05/2025

NARRATIVE

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***CONTINUE FROM 9099***

An internal incident report is completed, and the responsible party is contacted.” S2 stated, “In this situation, we assessed and called hospice, and notification to the person in charge happened right away.” S3 provided the incident report and change of condition log, which reflected that staff documented the fall, assessment, and communication with hospice. S4 also confirmed that she notified the med tech immediately after discovering the situation.

LPA’s review of the communication logs and call logs confirmed that notifications were made to hospice and to responsible parties after the incident. Documentation reviewed included the internal incident report with instructions and protocols for care following the fall. Interviews with staff were consistent in describing the procedure: caregivers alert the med tech and unit lead, complete incident documentation, and notify hospice and the responsible party.

Allegation: Staff does not meet training requirements - Unsubstantiated

LPA reviewed three staff files (S1–S3), including annual training logs, and continuing education records. LPA also reviewed R1's file. R1 is on hospice. W1 reported, “An untrained med tech who is not a nurse assessed whether or not my mother was okay.” Interviews with staff confirmed that the caregiver on duty notified the med tech, who then notified the nurse and hospice. S4 stated, “I notified the med tech right away to escalate it after finding out the situation in Room 119.”

***CONTINUE ON 9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250610101445

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 OAKLAND HILLS	FACILITY NUMBER: 019201329
	VISIT DATE: 09/05/2025

NARRATIVE

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***CONTINUE FROM 9099C***

Staff files reviewed by LPA contained documentation of orientation, and annual continuing education hours were reviewed.Training logs showed that caregivers and med tech had completed the mandated annual training. S3 provided LPA with the internal incident report and care plan for R1, which confirmed that documentation and reporting protocols were followed. Staff interviews with S1–S4 revealed facility’s process for immediate reporting to the med tech, escalation to the nurse, and notification of hospice and responsible parties.

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

.Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC9099 (FAS) - (06/04)

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