079200753-2-7-2022-15-AS-KHOS-CKSM7M-20221102092147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200753
Report Date: 02/07/2022
Date Signed: 02/07/2022 03:11:49 PM

Unsubstantiated

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
01/28/2022 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20220128163332

FACILITY NAME:	IVY PARK AT SAN RAMON		FACILITY NUMBER:	079200753
ADMINISTRATOR:	JOSEPH VILLANUEVA		FACILITY TYPE:	740
ADDRESS:	9199 FIRECREST LN		TELEPHONE:	(925) 803-9100
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	140	CENSUS: 100	DATE:	02/07/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Eugenia Smith, Executive Director		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff are not following Covid-19 protocols

INVESTIGATION FINDINGS:

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On 2/7/2022 at 2:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a complaint investigation for the above allegation. LPA met with Executive Director, Eugenia Smith and explained the purpose of the visit.

During the complaint investigation, at 2:10 PM, LPA toured facility with Executive Director and observed care staff wearing masks. LPA observed two kitchen staff in the kitchen with their mask below their chins. However, staff appeared to be six feet apart and there were no residents around. Interview with W1 revealed that facility has not had any issues with infection control.

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 and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

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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