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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201116
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:01:31 PM


Document Has Been Signed on 03/27/2024 04:01 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:162CENSUS: 153DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Caroline FrangiehTIME COMPLETED:
03:00 PM
NARRATIVE
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On 3/27/2024 at 1:50 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue 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. It was found that the incident actually occurred 1/31/2024. 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.

LPA interviewed witness S2 with the help of Health Services Director, Anelisse Ramirez to translate. S2 stated that while they were pushing the dish cart from the kitchen R1 was wandering in their briefs and approached S2 to ask a question. S2 responded with "OK" because they do not speak English. S2 then returned to the kitchen and came back out a few minutes later. S2 then observed R1 walking down the hall towards S1 who was looking at their phone. S1 ignored R1. S2 speculates that R1 was asking S1 to go to the bathroom based on the body language of R1. R1 raised their voice repeatedly to get the attention of S1 but S1 maintained looking at their phone. S1 then reached over to the left with phone still in hand to push R1 away. R1 then stumbled and braced thyself against the wall. S2 states that R1 looked down after balancing thyself and then walked away. S1 then made eye contact with S2 and rolled their eyes. S2 later reported what they witnessed.


Report continues on LIC 809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/27/2024
NARRATIVE
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Resident was in memory care and unable to recall. At the time of visit resident was no longer at the facility.

LPA spoke with ED about addressing reporting requirements for mandated reporters and ED informed LPA that they provided S2 as well as all facility staff with a training on the expectations.

THE FOLLOWING DEFICIENCIES ARE BEING CITED

  • S1 was observed physically abusing R1




The following deficiencies were observed (see LIC 809D) 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. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/27/2024 04:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
HSC
1569.269(a)(10)

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To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

This requirement was not met as evidenced by:
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Staff was terminated.
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Based on interviews and reports S1 pushed R1 thereby physically abusing them.
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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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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