079201116-3-24-2026-15-AS-BFOG-DSXLZ9-20260408091134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 03/24/2026
Date Signed: 03/24/2026 11:09:24 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
08/20/2025 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20250820161102

FACILITY NAME:	IVY PARK AT SAN RAMON		FACILITY NUMBER:	079201116
ADMINISTRATOR:	MORGAN, OREISHA		FACILITY TYPE:	740
ADDRESS:	9199 FIRCEST LANE		TELEPHONE:	(949) 744-5200
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	162	CENSUS: 158	DATE:	03/24/2026
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Executive Director, Gilbert Castro		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Lack of supervision resulting in resident being sexually abused at the facility.
Facility not following reporting requirements

INVESTIGATION FINDINGS:

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On 3/24/2026 at 10:40 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Gilbert Castro and explained the purpose of the visit.

During course of the investigation, LPA A Gomez conducted interviews with facility staff, and complainant. Documents including but not limited to: Residents Admission agreements, physician’s reports, care plans, and care notes were reviewed

Report Continues on LIC 9099-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-20250820161102

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, lack of supervision, resulting in resident being sexually abused at the facility LPA conducted interviews, reviewed R1 and R2’s care plan, R1 and R2’s physicians report, and care notes. LPA observed that R1 and R2 were both memory care residents with a diagnosis of dementia. On 8/13/2025 it is alleged that R2 entered R1’s room and sexually assaulted them. LPA interviewed S1 who is the lead for S3 who stated that on 8/13/2025 S3 had led R2 to Dining for breakfast. Approximately 30 minutes later, S3 noticed that R2 was not at dining. S1 states that other facility staff and S3 were still getting residents to dining for breakfast at this time. R2 was discovered in R1’s room during this time. S1 states that they were told that it appeared that R1 and R2 may have engaged in sexual activities. LPA conducted interviews with S2 S4 and S5. All staff stated that they had heard about the interaction between R1 and R2 however, residents have a personal right to engage in sexual activity, unless there is a court appointed conservator. LPA found that R1 and R2 are not conserved. LPA attempted to interview R1 but was unable to due to their dementia diagnosis. R2 was also unavailable to interview. LPA made attempts to contact S3 but was unable to interview S3 as they are not permanent staff. LPA was unable to determine if the interaction between R1 and R2 was consensual therefore, the allegation of lack of supervision resulting in resident being sexually abused at the facility is unsubstantiated.

Report Continues on LIC 9099-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)

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Control Number 15-AS-20250820161102

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

On the allegation facility not following reporting requirements LPA reviewed records and unusual incident reports. LPA observed that the facility reported the interaction between R1 and R2 on 8/18/2025 which is within title 22 guidelines of reporting requirements. LPA observed that the incident happened on 8/13/2025 was reported to police, responsible parties, and to licensing therefore the allegation facility not following reporting requirements is unsubstantiated.

Although the allegations 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)

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