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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201506
Report Date: 11/05/2025
Date Signed: 11/05/2025 04:18:42 PM

Document Has Been Signed on 11/05/2025 04:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:IVY AT BERKELEY, THEFACILITY NUMBER:
019201506
ADMINISTRATOR/
DIRECTOR:		STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:2000 DWIGHT WAYTELEPHONE:
(510) 900-8959
CITY:BERKELEYSTATE: CAZIP CODE:
94704
CAPACITY: 138CENSUS: 67DATE:
11/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Angeles Sticka, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 11/05/2025 at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident reported to Community Care Licensing Division (CCLD) on 10/22/2025. Upon arrival, LPA met with Executive Director (ED) Angeles Sticka and explained the purpose of the visit.

LPA obtained the following documents: Resident Roster, Resident Information Sheet, medical assessment dated (07/02/2025), Memory Care Staff schedule (week 10/12/25), In-Service "Elopement Drill" training staff sign-in sheet (dated 10/18/25 and 10/22/25), and Individualized Service Plan (dated 10/28/25).

LPA interviewed Staff (S1) who stated that on 10/17/2025, Resident (R1) eloped from the Memory Care (MC) unit. S1 reported that MC staff on duty did not observe R1 leaving the secured unit. According to S1, R1’s granddaughter was the individual who discovered that R1 was missing from their apartment and could not be located within the MC unit.

S1 stated that staff immediately initiated the facility’s elopement protocol, which includes: conducting a search of the MC unit and resident apartments. Checking the Assisted Living (AL) apartments, common areas, and the remainder of the building. Conducting an external neighborhood search. Contacting 911 if the resident cannot be located.

LIC809-C Continued...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: IVY AT BERKELEY, THE
FACILITY NUMBER: 019201506
VISIT DATE: 11/05/2025
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LIC809-C (Page 2)

S1 reported that staff contacted the Berkeley Police Department, and shortly thereafter, the facility received a call from Agrodolce Osteria, a local restaurant located on Shattuck Avenue, informing staff that R1 was at their establishment. R1’s daughter retrieved R1 from the restaurant and returned them safely to the facility.

S1 further stated that R1 has eloped twice to date, with the 10/17/2025 incident being the most recent occurrence. In response, the facility implemented door alarms on all emergency exits and conducted in-service training with MC staff on 10/18/2025 and 10/22/2025 regarding elopement procedures and resident supervision.

S1 also indicated that a 1:1 companion was arranged for R1 for five days following the incident; however, the family declined to continue the service due to the cost. S1 added that R1 was later observed walking on Milvia Street, but staff are still unsure how R1 managed to exit the MC unit and the building.

LPA reviewed R1’s Medical Assessment (MA), which indicated that R1 was able to leave the community unsupervised. LPA discussed this MA with S1, who confirmed that the response on the assessment was not accurate and did not reflect R1’s current condition or supervision needs.



The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 04:18 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/05/2025 at 03:11 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 AT BERKELEY, THE
FACILITY NUMBER: 019201506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2025
Section Cited
CCR
87468.2(a)(4)

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(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ...

This requirement was not met as evidence by:
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Administrator and Memory Care Director agreed to arrange a care conference with R1's responsible party to finalize an updated care plan that reflects R1's care needs.
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Based on interviews and record review the Licensee did not comply with the section cited above by not ensuring that Resident (R1) was provided safe and secure accommodations to meet their needs when R1 eloped from the Memory Care unit on 10/17/2025 without staff knowledge or supervision. This posed an immediate health and safety risk and personal rights to R1, who was later located off facility premises by family.
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Administrator will conduct an In-Service training with all staff and will submit participant sign in sheet, updated care plan and medical assessment to CCLD by POC due date.

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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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