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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200754
Report Date: 09/20/2023
Date Signed: 09/20/2023 11:49:53 AM


Document Has Been Signed on 09/20/2023 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CREEKFACILITY NUMBER:
079200754
ADMINISTRATOR:IRYN MACAMAYFACILITY TYPE:
740
ADDRESS:2175 YGNACIO VALLEY RDTELEPHONE:
(925) 932-3500
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:86CENSUS: 65DATE:
09/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wellness Nurse Julie Monterrosa, LVNTIME COMPLETED:
12:00 PM
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On 09/20/2023 at 09:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a Case Management visit concerning death of Resident R1 on 09/14/2023. The LPA stated the purpose of the visit to Wellness Nurse Julie Monterrosa, LVN.

LPA Sampair interviewed Nurse Monterrosa and Regional Operations Specialist (ROS) Eugenia Smith about the circumstances of R1's death. They explained that R1 returned to the facility on 09/14/2023 from Kaiser Hospital in Walnut Creek. This was after his 09/04/2023 emergency surgery for a fracture of his right femur at Kaiser Hospital in Walnut Creek. Upon R1's return on 09/14/2023, Hospice East Bay was there to return R1 to hospice care. R1, however, was experiencing a high level of pain that required skilled nursing care, so with the family's permission, R1 was transferred by Hospice East Bay to their hospice house, Brun's House, in Alamo for the skilled nursing care that he needed. On 09/15/2023, the family notified the facility that R1 was pronounced dead from Vascular Dementia at 6:48 PM on 09/14/2023 at Brun's House.

After the interview, the LPA reviewed the process and the proper form to use, the LIC624A, to report a death with the ROS and Nurse Monterrosa.

No citations issued during the visit.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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