019201329-9-10-2025-15-AS-YFLS-DLTQ4Y-20250924115106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201329
Report Date: 09/10/2025
Date Signed: 09/10/2025 02:00:10 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
01/13/2025 and conducted by Evaluator Ardalan Gharachorloo

COMPLAINT CONTROL NUMBER: 15-AS-20250113082533

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: 86	DATE:	09/10/2025
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Yolanda Harrell, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure that resident's incontinence needs are met
Staff are not following a resident's meal plan
Staff do not provide resident with housekeeping services
Staff do not administer resident's medications as prescribed
Staff do not ensure that the facility maintains a phone that is in working order
Staff do not assist a resident with receiving mail
Staff has not provided a resident's responsible party with a copy of facility fees
Staff did not safeguard a resident's confidential information
Staff do not provide resident with laundry service
Staff do not observe resident for change in conditions

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/10/2025 at 11:20 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings regarding above allegations.LPA met with Executive Director, Yolanda Harrell and explained the purpose of the visit.

During the course of the investigation LPA conducted an interviews with 8 staff (S1-S8), 3 residents (R1,R2,R3), and collected the following documents: Resident and staff roster, staff schedule, House keeping and laundry schedule,sample of care fees increase letter, R1's Ledger, special diet schedule and hospice files. LPA also reviewed R1,R2, and R3 files, and toured R1's room.

Staff do not ensure that resident's incontinence needs are met: Unsubstantiated

Licensing Program Analyst (LPA) conducted a tour of Resident 1's (R1) room, interviewed S1 and S2, and reviewed R1’s care plan along with the staff schedule. During the tour, R1 was found in his room in a clean and sanitary condition, with no indications of unmet incontinence needs.

***CONTINUE ON 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

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 5

Control Number 15-AS-20250113082533

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: 09/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***CONTINUE FROM 9099***

Interviews with S1, S2 and indicated that R1 receives regular assistance with incontinence care in accordance with their care plan. A review of the staff schedule revealed that sufficient staff were assigned to provide necessary care. LPA reviewed the care plan. The care plan detailed the frequency of incontinence checks and the type of support R1 should receive. A review of the incontinence care logs showed that staff documented each check and change. LPA also checked the log for how checks are being documented. These logs were complete, consistent, and matched the interventions written in the care plan. The staff schedule also confirmed that there are enough staff assigned to meet R1’s needs.

Allegation: Staff are not following a resident's meal plan: Unsubstantiated

LPA interviewed S1, S4, the head chef, and two kitchen staff (S6,S7). S1 stated that R1’s meal plan remains unchanged and continues to follow the guidelines set by hospice services, as outlined in the last care plan dated 08/2024. S1 also stated that she regularly checks in with kitchen staff to ensure R1s special diet needs are met. LPA also interviewed S4 who stated that “the special meal plan is posted for reference in the kitchen. LPA toured the kitchen and observed the meal plan posted in the kitchen. LPA also requested a sample of the food being served to R1 and interviewed R1 regarding his meals. R1 stated that “the food is fine”. LPA also interviewed R2 and R3 who stated they have no complaints about the food.

Allegation: Staff do not provide resident with housekeeping services: Unsubstantiated

LPA interviewed S1 who stated that “R1 has a designated housekeeping day and that “staff continuously provide housekeeping services as scheduled”. S1 provided documentation, including the housekeeping schedule and staff assignments, which confirmed that regular cleaning services are in place for R1. LPA also reviewed the housekeeping schedule, which reflected consistent and ongoing housekeeping services being provided. Additionally, LPA conducted a tour of R1’s room and observed that the room was clean and sanitary. LPA interviewed R2 and R3 who stated they have no issues with housekeeping. LPA also toured R2 and R3's room and were clean.

***CONTINUE ON 9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20250113082533

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: 09/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***CONTINUE FROM 9099C***

Allegation: Staff do not administer resident's medications as prescribed: Unsubstantiated

LPA reviewed R1’s physician reports and Medication Administration Records (MARs). LPA also interviewed S3 and S5, both of whom confirmed that they follow the MAR orders when administering medications to R1. A review of a sample of R1’s medications further indicated that they are being dispensed in accordance with the prescribed orders. Additionally, LPA interviewed S1 who stated that “staff strictly adhere to the MAR orders”. S1 also stated that she “advised W1 to contact her directly any time with any concerns to clarify any misunderstandings”.

LPA spoke with S1 and reviewed Resident 1’s (R1) Medication List for June and July 2024. The records showed that all medications were given as prescribed. S1 explained that the eye drops are marked “as needed,” and the nurse decides if R1 should get them after checking R1 condition.

Allegation: Staff do not ensure that the facility maintains a phone that is in working order: Unsubstantiated

LPA checked the facility phone line and conducted a sample phone call, confirming that the phone was in working order. LPA also interviewed S1 who stated that the facility maintains a phone line accessible to all residents 24/7 and that it remains in always working condition. Additionally, LPA interviewed the concierge (S7), who confirmed that residents use the phone daily. S7 also stated that staff regularly transfer calls and deliver messages to residents as needed. LPA also interviewed R2 and R3 who stated that they have no issues with the phone line.

Allegation: Staff do not assist a resident with receiving mail: Unsubstantiated

LPA interviewed the concierge (S7), who stated that mail is delivered to residents daily. LPA also reviewed a sample of mail. LPA observed that some mails have been delivered to resident’s room. LPA interviewed S1, who confirmed that front desk staff are responsible for ensuring that mail is delivered directly to residents’ rooms. S7 provided examples of mail that had been recently delivered to residents. LPA observed 2 envelopes on the table next to R1. LPA interviewed R2 who stated that "I see mails at my front door daily". R3 also stated that she has no concerns with the mails.

***CONTINUE ON 9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20250113082533

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: 09/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***CONTINUE FROM 9099C***

Allegation: Staff has not provided a resident's responsible party with a copy of facility fees - Unsubstantiated

LPA interviewed S1, who stated that a letter notifying the resident’s responsible party of the facility fee increase was sent out 90 days in advance. S1 stated that W1 received a copy of this letter, which outlined the updated care fees. Additionally, S1 clarified that all facility fees were increased at the same time for all residents. LPA reviewed the admission agreement, a copy of the dated notification letter disclosing the increase, as well as the facility ledger and correspondence documents, which showed that the required notice was provided.

Allegation: Staff did not safeguard a resident's confidential information - Unsubstantiated

LPA toured the medication room and the designated storage area for resident and staff files. LPA observed that all doors to these sensitive areas were restricted and locked. Additionally, LPA interviewed S2 and S3, both of whom stated that medication records are secured with password protection and can only be accessed by authorized staff. LPA also interviewed S1 who stated that all areas containing confidential resident information are secured and only accessible to authorized personnel.

Allegation: Staff do not provide resident with laundry service: Unsubstantiated

LPA interviewed S1, who stated that the facility follows a designated laundry schedule for all residents. S1 stated that S1 meets regularly with shift managers and staff to ensure that scheduled laundry services are provided. S2 stated that the shift reports are conducted daily to maintain accountability for resident care tasks, including laundry services. S1 provided LPA with a copy of the facility’s laundry schedule, which outlines the assigned service times. LPA also interviewed S8 who stated that laundry services are completed based on the schedule provided by resident’s care coordinator. LPA toured the laundry room and interviewed R2 and R3 who stated no concerns with the laundry service.

***CONTINUE ON 9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20250113082533

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: 09/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***CONTINUE FROM 9099C***

Staff do not observe resident for change in conditions: Unsubstantiated

LPA reviewed the R1’s physician report, medication records, needs and services plan and hospice care plan. S1 also provided the staff communication sheet related to the logging of changes in condition to the LPA. LPA interviewed S1 who stated that the facility’s nurse is scheduled to check in with residents daily to assess any changes in condition. S1 stated that any observed changes are documented accordingly. LPA reviewed the log during the interview as well as the updated communication log with hospice. LPA observed that observation notes are dated, and care staff, med tech and wellness nurse log observations for residents.

This agency has investigated the complaint allegations 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 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: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5