079200754-9-8-2023-15-AS-KHOS-CVKLQD-20230911085722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200754
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:43:37 PM

Substantiated

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
09/05/2023 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230905125605

FACILITY NAME:	IVY PARK AT WALNUT CREEK		FACILITY NUMBER:	079200754
ADMINISTRATOR:	IRYN MACAMAY		FACILITY TYPE:	740
ADDRESS:	2175 YGNACIO VALLEY RD		TELEPHONE:	(925) 932-3500
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	86	CENSUS: 65	DATE:	09/08/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Regional Operations Specialist Eugenia Smith		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not issue a proper refund to resident's authorized representative

INVESTIGATION FINDINGS:

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On 09/08/2023 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to investigate the allegation above. LPA stated the purpose for the visit to Marketing Director Sahar Khaleqi.

At 9:42 AM, LPA Sampair called Senior Accountant Kristy Hartman who stated that no refund had yet been issued to Resident 1 (R1)'s estate. Upon arriving at 9:45 AM, Regional Operations Specialist Eugenia Smith confirmed that no refund had been issued to R1's estate.

Based on the data collected, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED. Deficiency cited per Title 22 California Code of Regulations is listed on the LIC9099-D. 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 via email.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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-20230905125605

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 WALNUT CREEK	FACILITY NUMBER: 079200754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/15/2023 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	1569.652 Termination of admission agreement upon death of resident . . . refund of fees paid . . . (c) A refund of any fees paid in advance . . . shall be issued . . . within 15 days after the personal property is removed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Refund issued and sent to R1's estate during visit.
	8 9 10 11 12 13 14	Based on a review of the records, the licensee did not comply with the section above. 66 days after Resident 1 (R1)'s death and all property removed, no refund had been issued, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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