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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201116
Report Date: 02/28/2024
Date Signed: 02/28/2024 01:41:47 PM


Document Has Been Signed on 02/28/2024 01:41 PM - 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 SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:COONS, JENNIFER SFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:140CENSUS: 142DATE:
02/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director, Caroline FrangiehTIME COMPLETED:
12:00 PM
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On 2/28/2024 at 11:16 AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 2/06/2024. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit.

It was reported that on 02/02/2024 that a team member allegedly observed another team member push a resident living in memory care.Resident was observed to have no injuries or recollection of the event. Resident did not fall as they were near a wall and was able to stabilize thyself. Health Services Director, Anelisse Ramirez-LVN, was called to assess for possible injuries. Assessment resulted in no visible injuries. Resident was asked about the event, which they were unable to recall.

The staff (S1) alleged of abuse was terminated effective 2/12/2024. LPA obtained a copy of the Disciplinary Action Notice for S1 and contact information for witnesses and all parties involved. LPA will return at a later date to continue investigation.

No Deficiencies will be cited at this time


Exit interview conducted. A copy of this report provided via e-mail.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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