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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 03/24/2026
Date Signed: 03/24/2026 10:24:20 AM

Unsubstantiated


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
06/03/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250603102000
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: 158DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, Gilbert CastroTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility staff neglected resident contributing to questionable death
INVESTIGATION FINDINGS:
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On 3/24/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegation. LPA met with Executive Director, Gilbert Castro and explained the purpose of the visit.

During course of the investigation, the Department obtained documents including but not limited to: R1’s admission agreement, physician’s report, care plan, medication log, incident reports, discharge notes, death certificate, and medical records.

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

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
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
Control Number 15-AS-20250603102000
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: 03/24/2026
NARRATIVE
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PG. 2

On the allegation “Facility staff neglected resident contributing to questionable death” the following was found. R1 was admitted to the facility on 4/29/2024. On 8/8/24, the facility staff took over medication administration for R1 per their responsible parties request. On 8/27/24, R1 was having chest pains and was sent to San Ramon Valley Regional Hospital. R1 was diagnosed with low potassium. R1 was treated and sent back to the facility the same day with no new orders. On 9/11/24, R1 was having trouble breathing and was sent to the hospital on 9/12/24. R1 was diagnosed with low potassium levels and bloody fluid coming from the lungs. R1 was discharged from the hospital on 9/26/24. R1 did not return to the facility and was transferred to home health care at their responsible parties home. On 9/28/24, R1 was having shortness of breath and weakness and was transported back to the hospital while in their families care. On 10/4/24, R1 was transferred to a skilled nursing facility (SNF). On 11 /7/24, R1 was having trouble breathing while at the SNF. R1’s lungs were drained and appeared to be doing better. On 11/12/24, R1 tested positive for MRSA and went back to the hospital. R1 was placed on hospice and passed at the hospital on 11/17/24. It was alleged that Ivy Park San Ramon missed R1’s potassium medication however it could not be confirmed after a review of the Medication Administration Record (MAR ) For 7/01/2024-9/26/2024. R1 was also taking medication for congestive heart failure, medications were classified as a diuretic (water pill), a common side effect is a drop in potassium level (hypokalemia). According to Mayo clinic hypokalemia is, “Low potassium a condition in which the potassium level in your bloodstream is lower than is typical. The medical term for this condition is hypokalemia”.


Report continues on LIC9099-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250603102000
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: 03/24/2026
NARRATIVE
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PG. 3

R1 also had a complex past medical history with comorbidities and was taking multiple medications as prescribed. A copy of R1’s death certificate revealed R1 passed away on 11/17/2024 at JOHN MUIR MEDICAL CENTER-WALNUT CREEK and the cause of death was listed as chronic respiratory failure and heart failure; the etiology is unknown. A causal connection could not be established between the care at the facility and R1s expiration. Therefore, the allegation “Facility staff neglected resident contributing to questionable death” is 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. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3