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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:55:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/15/2023 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20230315155513
FACILITY NAME:IVY PARK AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:SMITH, EUGENIAFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:140CENSUS: 119DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jennifer Coons, Executive Director TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff not administering medication in a timely manner
INVESTIGATION FINDINGS:
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On 5/10/2023 at around 9:10AM, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct an unannounced complaint visit and deliver the investigation finding. LPA met Executive Director Jennifer Coons, LPA explained the purpose of the visit.

Allegation: Facility staff not administering medication in a timely manner
Based on record’s review on physician's order and Medication Administrator record (MAR),it was revealed that one of resident’s (R6's) over-the-counter medication (OTC) was ordered to be given 1 tablet by mouth daily with breakfast, however, resident (R6) medication was not given to resident from February 1, 2023, February 28, 2023.
Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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 4
Control Number 15-AS-20230315155513
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
87465(c)(2)
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If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident…(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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Administrator has agreed to retrain medication technician staff on medication administration. Administrator will submit staff sign-in sheet and training materials to CCLD by POC date.
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Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's order for R6's medication which poses an immediate health and safety risk to persons 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/15/2023 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20230315155513

FACILITY NAME:IVY PARK AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:SMITH, EUGENIAFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:140CENSUS: 119DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jennifer Coons, Executive Director TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Facility had insufficient staff
Staff yelled at resident
Facility not providing adequate care for resident
INVESTIGATION FINDINGS:
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On 5/10/2023 at around 9:15AM, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct an unannounced complaint visit and deliver the investigation findings. LPA met Executive Director Jennifer Coons, LPA explained the purpose of the visit.

Allegation: Facility had insufficient staff

LPA reviewed staff schedule for the facility, facility has Med Tech, caregivers, and management support available on schedule. Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with residents and residents reported that they are happy living at the facility and had no issues around staff availability to meet their needs. Residents that were interviewed reported that facility staff attend to their needs.
...Continue to LIC9099C...

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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 4
Control Number 15-AS-20230315155513
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: IVY PARK AT SAN RAMON
FACILITY NUMBER: 079201116
VISIT DATE: 05/10/2023
NARRATIVE
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Allegation: Staff yelled at resident

During the course of investigation, LPA conducted residents and staff interview. Based on interview with staff, they denied witnessing or knowing any staff that yelled at the residents in care. Staff stated that they have not witnessed or heard any staff acting inappropriate behavior towards residents in care. Based on residents interview they denied witnessing or hearing any staff yelling at residents in care.

Allegation: Facility not providing adequate care for resident

During the course of investigation, LPA conducted records review, interview with staff and residents. Records review on physician’s report and care plan revealed that resident (R1) was ambulatory and does not require toilet assist. Staff stated that for residents that needs incontinence care, the care staff checks on them at least every 2-3 hours to meet the residents needs.

LPA observed during the visit that residents are comfortable, well dressed and staff are attending to each resident in care.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4