079201116-10-20-2023-15-AS-KHOS-CX4NFN-20231030102548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:14:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/16/2023 and conducted by Evaluator Paris Watson

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231016103234

FACILITY NAME:	IVY PARK AT SAN RAMON		FACILITY NUMBER:	079201116
ADMINISTRATOR:	COONS, JENNIFER S		FACILITY TYPE:	740
ADDRESS:	9199 FIRCEST LANE		TELEPHONE:	(949) 744-5200
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	140	CENSUS: 143	DATE:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Melissa Del Dosso , Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility in disrepair.
Facility is malodorous.

INVESTIGATION FINDINGS:

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On 10/20/2023 at 9:30 AM Licensing Program Analysts (LPAs) P. Watson and A. Gomez arrived unannounced to conduct a complaint investigation for the above allegations. LPAs met with Executive Director, Melissa Del Dosso, and explained the purpose of the visit.

During the course of the investigation, LPAs toured facility and interviewed staff and residents.

It was alleged that Facility in disrepair and Facility is malodorous, based on interviews with staff (S2, S3, S4 and S5), the exhaust fans in the kitchen have been broke for about a week. S4 stated that the facility has contacted Cintas to inspect and repair the fan, S4 has reached out to the company multiple times and is waiting for a call back.

Report continues on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20231016103234

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT SAN RAMON	FACILITY NUMBER: 079201116
	VISIT DATE: 10/20/2023

NARRATIVE

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S3 and S4 stated that the facility has taken action to alleviate any odor that has been caused by the disrepair such as opening doors and windows and placing a fan in the kitchen area to blow the smell away from dinning area. S2 and S3 stated that the smell is primarily in the kitchen area and can be smelled when kitchen staff open the doors to deliver food. S5 stated that at one point the odor did linger into the hallway closets to the kitchen area but recently they have not smelled any odors. Based on interviews with residents, R4 stated that they were informed by staff that the exhaust fan in the kitchen was broken and that there may be an odor, R4 stated that they smelled a slight odor in the kitchen area at one point but did not smell anything recently.

Based on LPAs observations and interviews, although the allegations may have happened or is valid, the facility is taking action to make repairs and alleviate odors, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

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