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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201506
Report Date: 07/21/2026
Date Signed: 08/12/2026 02:01:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/17/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260417112651
FACILITY NAME:IVY AT BERKELEY, THEFACILITY NUMBER:
019201506
ADMINISTRATOR:STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:2000 DWIGHT WAYTELEPHONE:
(510) 900-8959
CITY:BERKELEYSTATE: CAZIP CODE:
94704
CAPACITY:138CENSUS: 113DATE:
07/21/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angeles Sticka, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure resident’s call button was not in disrepair
Staff inappropriately took resident’s medication
Staff did not effectively communicate with resident
INVESTIGATION FINDINGS:
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On 8/12/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM/ED). LPA explained the purpose of the visit with ADM/ED. This is an AMENDMENT to original complaint delivered on 07/21/26.

During investigation, LPA interviewed reporting party (RP), resident (R1), staff (ED, S1), Ombudsmen (OMB1, OMB2) and obtained the following documents: Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, Needs & Services plan, Assessment/Pre-appraisal report, After Discharge Summary report, Progress Notes, emails between RP and ED.

Continued on next page, LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
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 7
Control Number 15-AS-20260417112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: IVY AT BERKELEY, THE
FACILITY NUMBER: 019201506
VISIT DATE: 07/21/2026
NARRATIVE
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Allegation: Staff did not ensure resident’s call button was not in disrepair
Investigation Finding: Substantiated
During investigation, LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED, S1, S2, S5) and reviewed R1’s documents. On 04/23/26, staff (S1, S2) confirmed with LPA that they did not test the emergency call button issued to R1 during the onboarding process on 03/27/26 to ensure it was operational. R1 pressed the emergency call button around 5PM the same day and was unable to reach staff for assistance for over 3 hours (5PM to 8:15PM) due to a non-operating emergency call button. R1 stated she was left in the dark, was unable to transfer from her wheelchair to the bed and did not have her meal during this time. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not ensure residents call buttons were not in disrepair was found to be substantiated.

Allegation: Staff inappropriately took resident’s medication


Investigation Finding: Substantiated
During investigation, LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED, S1, S5) and reviewed R1’s documents. On 04/01/26, POA/RP sent an email approving staff medication management for R1. On 04/03/26, he rescinded the approval via email. On 04/07/26, staff confirmed with LPA that they took R1’s medications despite the 04/03/26 email stating that R1 does not require medication management. Her medications were returned before 7PM on 04/07/26 as requested by POA. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff inappropriately took resident’s medication was found to be substantiated.

Continued on next page, LIC 9099-C pg2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20260417112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: IVY AT BERKELEY, THE
FACILITY NUMBER: 019201506
VISIT DATE: 07/21/2026
NARRATIVE
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Allegation: Staff did not effectively communicate with resident
Investigation Finding: Substantiated
During investigation, LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED, S1, S2) and reviewed R1’s documents. R1 stated that on 03/31/26, she waited for over an hour at the front desk for her scheduled post-surgical transport which she booked in advance. S4 stated they did not notify R1’s POA about the situation on 03/31/26 for an alternate solution. Lack of communication with R1’s POA on 03/31/26 resulted in R1 waiting a long time and finally being told after waiting for over an hour that her transport was cancelled since no caregiver was available to accompany her to her doctor’s appointment. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not effectively communicate with resident was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20260417112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY AT BERKELEY, THE
FACILITY NUMBER: 019201506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2026
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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By POC due date, ED agrees to complete and submit to CCL in-service staff retraining on ensuring residents’ call buttons are operational prior to issuing to new residents and to ensure residents’ personal rights to proper care, supervision and services are in compliance with Section 87303(a) regulations.
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This requirement was not met as evidenced by staff not ensuring resident’s call button was operational which posed a potential health & safety risk to residents in care
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Type B
08/21/2026
Section Cited
CCR
87468(a)(1)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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By POC due date, ED agrees to complete and submit to CCL in-service staff retraining on proper implementation of written medication management requests in compliance with Section 87468(a)(1) regulations.
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This requirement was not met as evidenced by staff failing to follow POA’s current written medication management communication which posed a potential health & safety risk to resident 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20260417112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY AT BERKELEY, THE
FACILITY NUMBER: 019201506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2026
Section Cited
CCR
87468.1(a)(8)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs
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By POC due date, ED agrees to complete and submit to CCL in-service staff retraining on timely communication with residents’ responsible party on medical transportation needs in compliance with Section 87468.1(a)(8) regulations.
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This requirement was not met as evidenced by staff failing to timely communicate with resident’s responsible party on medical transportation requirements which posed a potential health & safety risk to resident 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/17/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260417112651

FACILITY NAME:IVY AT BERKELEY, THEFACILITY NUMBER:
019201506
ADMINISTRATOR:STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:2000 DWIGHT WAYTELEPHONE:
(510) 900-8959
CITY:BERKELEYSTATE:CAZIP CODE:
94704
CAPACITY:138CENSUS: 113DATE:
07/21/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angeles Sticka, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff did not ensure resident had transportation for appointment
Staff do not effectively communicate with resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/21/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM/ED). LPA explained the purpose of the visit with ADM/ED.

During investigation, LPA interviewed reporting party (RP), resident (R1), staff (ED, S1), Ombudsmen (OMB1, OMB2) and obtained the following documents: Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, Needs & Services plan, Assessment/Pre-appraisal report, After Discharge Summary report, Progress Notes, emails between RP and ED.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20260417112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: IVY AT BERKELEY, THE
FACILITY NUMBER: 019201506
VISIT DATE: 07/21/2026
NARRATIVE
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Allegation: Staff did not ensure resident had transportation for appointment
Investigation Finding: Unsubstantiated
LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED), Ombudsmen (OMB1, OMB2) and reviewed R1’s documents. LPA interviewed R1 who stated that on 03/31/26, staff failed to transport her to a post-surgical appointment she had arranged in advance because she assumed a caregiver would accompany her to her doctor’s appointment which the facility could not provide. ED stated she communicated to R1’s POA that she would oversee R1’s post-surgical rescheduled doctor’s appointment to ensure it was done. However, staff communicated to ED that R1 cancelled her rescheduled post-surgical doctor visit transport because she told staff that her responsible party (POA) will take her instead. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not ensure resident had transportation for appointment is unsubstantiated.

Allegation: Staff are not responding to residents’ call buttons in a timely manner


Investigation Finding: Unsubstantiated
LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED), Ombudsmen (OMB1, OMB2) and reviewed R1’s documents. During visit on 04/23/26, LPA tested R1’s call button and staff appeared within 10 minutes of the call button alert. On 07/06/25, OMB1 and OMB2 confirmed with LPA that they tested residents’ call buttons on 04/19/26 and staff showed up within 10 minutes of the call button alerts. LPA interviewed random residents (R2, R3) who stated they did not have any concerns regarding staff responding to call button alerts because they respond within 10 minutes.. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not responding to residents’ call buttons in a timely manner is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7