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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 08/04/2025
Date Signed: 08/04/2025 10:51:33 AM

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
03/10/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250310140445
FACILITY NAME:IVY PARK AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:MORGAN, OREISHAFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:162CENSUS: 142DATE:
08/04/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Executive Director (ED), Oreisha MorganTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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9
Staff did not provide proper medication assistance to resident in care
INVESTIGATION FINDINGS:
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On 8/4/2025 at 8:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver amended findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit.

During the investigation, LPA conducted interviews, toured facility, and reviewed files. LPA conducted interviews. On 4/23/2025 LPA interviewed S1 and S2.

Report continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
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 4
Control Number 15-AS-20250310140445
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 SAN RAMON
FACILITY NUMBER: 079201116
VISIT DATE: 08/04/2025
NARRATIVE
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On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R1 MAR where medication was marked as administered however R1 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight.

LPA already cited for 87465(a) on complaint: 15-AS-20241203085000

The following deficiencies were observed (see LIC 809D on complaint 15-AS-20241203085000) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
03/10/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250310140445

FACILITY NAME:IVY PARK AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:MORGAN, OREISHAFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:162CENSUS: 146DATE:
08/04/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Executive Director (ED), Oreisha MorganTIME COMPLETED:
10:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refused to accept resident back to the facility
Staff did not allow resident's representative to access resident's records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/4/2025 at 8:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver amended findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit.

During the investigation, LPA conducted interviews, toured facility, and reviewed files. LPA conducted interviews with ED and W1. LPA also reviewed corespondences available between R1's responsible person and the facility.

Report continues on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250310140445
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 SAN RAMON
FACILITY NUMBER: 079201116
VISIT DATE: 08/04/2025
NARRATIVE
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3
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10
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12
13
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During the course of the investigation LPA interviewed W1 and reviewed correspondences with R1's responsible party. LPA was unable to identify where the facility refused to accept R1 back into care after R1 was sent out to the hospital. LPA also observed that R1's responsible party requested R1's the medication list on 8/28/2024 at 08:21:13 PM PDT via email and that the facility's Health and wellness director (HWD) at the time provided the medication list on 8/28/2024 at 9:30 PM. R1's power of attorney also requested R1's full record and provided proof of POA on 1/22/2025. The initial request was made on or around 1/14/2025 however the proof of POA documents still needed to be submitted based on the correspondences provided. At the time of the request R1 was not a resident of the facility and had passed away. R1 left Ivy park in September of 2024 and passed away a couple of moths later at an unrelated facility. The facility provided the requested records to R1's POA on 1/22/2025 via email as requested by the POA. Therefore the allegations of "Staff refused to accept resident back to the facility" and "Staff did not allow resident's representative to access resident's records" are Unsubstantiated.

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.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4