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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 09/16/2025
Date Signed: 09/16/2025 02:36:03 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
07/29/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250729114132
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:
09/16/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Regional OPs Specialist, Jessica PryorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide assistance to resident in a timely manner.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 9/16/2025 starting at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings. LPA met with Regional OPs Specialist (ROS), Jessica Pryor and explained the purpose of the visit.

During the course of the investigation LPA reviewed files, tested quipment, and made observations. On the allegations Staff did not provide assistance to resident in a timely manner and Facility is in disrepair the following was found:

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

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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 5
Control Number 15-AS-20250729114132
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: 09/16/2025
NARRATIVE
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On 8/1/2025 LPA conducted tests on residents call button. LPA found that R1's pendant was not working properly and that staff were not notified when it was pressed therefore they were not able to meet the residents need in a timely manner. LPA asked staff when they came to help R1 get ready for meal time if they received a notification for R1's pendent being pressed and they stated "no". During the observation Health and Wellness Director was present. Therefore the allegations are substantiated.

***LPA assessed a civil penalty for repeat violation ($250)***

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

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

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250729114132
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2025
Section Cited
CCR
87307(d)(2)
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(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair...

This requirment was not met as evidence by:
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By POC facility agrees to inspect and replace residents personal call buttons as neccessary and notify CCLD
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Based on observations and interview the facility did not comply with the following by R1's call button being in disrepair which poses a potential safety and personal rights violation to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/29/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250729114132

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:
09/16/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Regional OPs Specialist, Jessica PryorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff charged resident for services not rendered.
Staff not following residents care plan
Staff speak to resident inappropriate
INVESTIGATION FINDINGS:
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On 9/16/2025 starting at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings. LPA met with Regional OPs Specialist (ROS), Jessica Pryor and explained the purpose of the visit.

During the course of the investigation LPA reviewed files, resident records, and made observations. On the allegations Staff charged resident for services not rendered, Staff not following residents care plan, and Staff speak to resident inappropriate the following was found:

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

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250729114132
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: 09/16/2025
NARRATIVE
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On 9/12/2025 LPA reviewed ledgers for a sample of residents. LPA observed that there was a substantial credit for R1. LPA spoke with BOD and ROS regarding the credit to see if they were connected to the allegation of "Staff charged resident for services not rendered". LPA found that the credit was because the resident was overcharged due to an accounting error. LPA reviewed R1's careplans from 2023-present and found that the level of care has not changed. LPA however did observe on one of the careplans that a special code was not inputted correctly which triggered the extra charges.

On 8/1/2025 LPA visited with R1, R2, R3 and R4. LPA observed that R1 was refusing care as outlined in their careplan. R2, R3, and R4 did not note any concerns with the level of care that they were being provided and LPA did not observe any concerns. LPA was unable to interview R1 however R2, R3 and R4 all expressed satisfaction with the staff and did not express any concern with staff speaking to them inappropriately. On 9/12/2025 LPA spoke with BOA who stated that there was a concern with an interaction between S1 and R5 however it was found that it did not indicate S1 speaking inappropriately to R5. Therefore the above allegations 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.

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

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5