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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:02:54 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
06/03/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240603145326
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: 155DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Director of Transitions & Acquisitions, Michael FountainTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Fire Exit is being blocked
INVESTIGATION FINDINGS:
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On 6/13/2024 at 12:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct an initial 10 day complaint visit and deliver findings. LPA explained the purpose of the visit to Director of Transitions & Acquisitions, Michael Fountain

LPA toured the facility with Director including but not limited to stairwells, common areas, and kitchen. During tour LPA observed a shampoo machine to be blocking fire exit located in 1st floor stairwell behind door 6. During the 10-day complaint visit LPA obtained a copy of facility map. The department also received a photo showing the same carpet shampooer located in the stairwell behind door 6 on a different occasion.

Based on LPAs observations, 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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 3
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
06/03/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240603145326

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: 155DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Director of Transitions & Acquisitions, Michael FountainTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Facility does not have an updated emergency disaster plan
Facility does not have an evacuation chair in each stairwell
Staff are not conducting quarterly emergency drills
INVESTIGATION FINDINGS:
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On 6/13/2024 at 12:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct an initial 10 day complaint visit and deliver findings. LPA explained the purpose of the visit to Director of Transitions & Acquisitions, Michael Fountain

LPA toured the facility with Director including but not limited to stairwells, common areas, and kitchen. During tour LPA observed that each stairwell has an emergency evacuation chair. LPA observed that emergency disaster plan is up to date. LPA observed that emergency drills are up to date. LPA obtained copies of the Emergency Disaster plan, Fire Drill log, and facility map.

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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20240603145326
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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
06/13/2024
Section Cited
CCR
87203
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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic

This requirement is not met as evidence by:
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Staff removed and stored shampooer in a safe location not blocking a fire exit.
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Based on observation the fire exit in stairwell behind door six was blocked by an industrial shampoo machine which posed an immediate health and safety risk 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3