079201116-4-12-2023-15-AS-YFLS-CT8W5D-20230628165859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 04/12/2023
Date Signed: 04/12/2023 11:14:13 AM

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
03/06/2023 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230306120048

FACILITY NAME:	IVY PARK AT SAN RAMON		FACILITY NUMBER:	079201116
ADMINISTRATOR:	SMITH, EUGENIA		FACILITY TYPE:	740
ADDRESS:	9199 FIRCEST LANE		TELEPHONE:	(949) 744-5200
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	140	CENSUS: 118	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Melissa Malek, Regional Director of Health Services		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Facility staff who are engaged in food preparation and service did not protect resident meals from contamination.

INVESTIGATION FINDINGS:

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On 4/12/23 starting at 10:10 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. LPA met with Melissa Malek, Regional Director of Health Services and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, reviewed records, collected documents and interviewed staff, and residents. It was alleged facility staff who are engaged in food preparation and service did not protect resident meals from contamination. However, based on record review of incident report, facility had an outbreak of norovirus. LPA interviewed 4 residents and 4 of 4 residents stated although they exhibited symptoms, it was not due to food poisoning.

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 to Melissa Malek, Regional Director of Health Services.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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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