079201116-4-12-2023-15-AS-KHOS-CWVNVB-20231023104740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 04/12/2023
Date Signed: 04/12/2023 11:11:31 AM

Unsubstantiated

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
11/04/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20221104082159

FACILITY NAME:	IVY PARK AT SAN RAMON		FACILITY NUMBER:	079201116
ADMINISTRATOR:	SMITH, EUGENIA		FACILITY TYPE:	740
ADDRESS:	9199 FIRCEST LANE		TELEPHONE:	(949) 744-5200
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	140	CENSUS: 118	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Melissa Malek, Regional Director of Health Services		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Facility failed to provide a safe environment for resident
Facility did not report incident to authorized representative in a timely manner
Facility did not call 911 in a timely manner

INVESTIGATION FINDINGS:

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On 4/12/23 starting at 10:10 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. LPA met with Melissa Malek, Regional Director of Health Services and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, reviewed records, collected documents and interviewed staff, and witness. It was alleged facility failed to provide a safe environment for resident. However, based on record review, maintenance for heating and air conditioning units are conducted quarterly. LPA observed last maintenance was completed on 7/30/22.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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-20221104082159

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: 04/12/2023

NARRATIVE

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It was alleged facility did not report incident to authorized representative in a timely manner. However, interview with 2 of 3 staff revealed that S3 contacted R1's responsible party, but since it went to voicemail, S3 contacted the next family member listed on the emergency contact.

It was alleged, facility did not call 911 in a timely manner. During record review and interview with W1, it was revealed that the smoke detectors in rooms are currently not being monitored by the fire alarm company. However, LPA discovered during an interview with S3 that once S3 was informed of the incident and smelled smoke in R1's apartment, S3 immediately contacted 9-1-1.

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.

Exit interview conducted and a copy of this report provided to Melissa Malek, Regional Director of Health Services.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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