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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201116
Report Date: 03/24/2026
Date Signed: 03/25/2026 08:01:40 AM

Document Has Been Signed on 03/25/2026 08:01 AM - 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/
DIRECTOR:		MORGAN, OREISHAFACILITY TYPE:
740
ADDRESS:9199 FIRCREST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 162CENSUS: 158DATE:
03/24/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Executive Director, Gilbert CastroTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 3/24/2026 at 11:30 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct the Annual Continuation Inspection to complete the Annual Required Inspection that began on 3/6/2026. LPA met with Executive Director, Gilbert Castro and explained the purpose of the visit.

On 3/24/2026 LPA reviewed 6 resident records and 5 staff records. 5 of 5 associated to the facility. Emergency Disaster Plan was last reviewed on 3/13/2026. Emergency disaster drill was last conducted on 3/8/2026.
THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT 3/6/26:
  • Downstairs common bathroom emergency call button not notifying caregivers pagers- disrepair ***
  • Dangerous Items identified: gardening sheers unlocked in activities room under sink, chemicals unlocked under sink/ butane, room 196 memory care (mc) hot tools, room 297 mc unlocked cleaning supplies/chemical hot tools.
  • Not enough staffing memory care; observed residents left unattended in activities room (2 caregivers on the floor for 30 residents. 1 upstairs 1 down), staff were also unaware that MC has emergency call buttons.
  • Room 293 Incontinence not properly disposed creating an Odor (thrown in open waste basket by bed)
  • Hot water measured at 129.2 degrees F room 269 ***
  • R3, R4, R5,and R6 appraisals of needs and services not up to date


***Civil Penalties assessed for repeat violations in 12 months $250 X 2***

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2026:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

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.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/25/2026 08:01 AM - It Cannot Be Edited


Created By: Alona Gomez On 03/24/2026 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the hot water measuring at 129.2 degrees F in room 269 which poses an immediate safety risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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By POC Facility agrees to monitor and adjust the boilers to ensure that the water temperature does not exceed 120 degrees F and notify CCLD
Request Denied
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having accesable gardening sheers unlocked in activities room under sink, chemicals unlocked under sink/ butane, room 196 hot tools, room 297 unlocked cleaning supplies/chemical hot tools which poses an immediate safety risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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By POC facility agrees to identify all accesiable dangerous items and secure and notify CCLD
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/25/2026 08:01 AM - It Cannot Be Edited


Created By: Alona Gomez On 03/24/2026 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87303(f)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having Room 293 Incontinence not properly disposed creating an Odor which posed a potential health and personal rights risk to persons in care.
POC Due Date: 03/06/2026
Plan of Correction
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Items disposed of POC clear
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 03/25/2026 08:01 AM - It Cannot Be Edited


Created By: Alona Gomez On 03/24/2026 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not enough staffing memory care; observed residents left unattended in activities room (2 caregivers on the floor for 30 residents. 1 upstairs 1 down), and staff were not aware (compitent) that MC has emergency call buttons which poses a potential personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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By POC facility agrees to hire more staff and train them and notify CCLD

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 03/25/2026 08:01 AM - It Cannot Be Edited


Created By: Alona Gomez On 03/24/2026 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review, the licensee did not comply with the section cited above in 4 out of 5 residents records review not having an updated annual appraisal which poses a potential personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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By POC Facility agrees to review all residents appraisals and ensure they are up to date and notify CCLD
Request Denied
Type B
Section Cited
CCR
87307(d)(2)
(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in downstairs common bathroom emergency call button not notifying caregivers pagers which poses a potential personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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By POC facility agrees to verify all call buttons and pagers are opperational and notify CCLD
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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