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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 05/14/2025
Date Signed: 07/01/2025 02:54:01 PM

Substantiated


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
12/03/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20241203085000
FACILITY NAME:IVY PARK AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:MORGAN, OREISHAFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:162CENSUS: 146DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Orisha MorganTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility is in disrepair
Staff are not following the residents care plan
Facility does not send incident reports as required
Staff are not providing medication as prescribed
INVESTIGATION FINDINGS:
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***THIS IS AN AMENDED REPORT***
On 7/1/2025 at 2:40PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver amended findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit.

During the investigation, LPA conducted interviews, toured facility, and reviewed files. On 12/09/2024 LPA reviewed interviewed ED. On 4/23/2025 LPA interviewed S1 and S2. LPA also obtained corespondences regarding varios residents.

Report continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 7
Control Number 15-AS-20241203085000
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: 05/14/2025
NARRATIVE
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On the allegations Facility is in disrepair, Staff are not following the residents care plan
Facility does not send incident reports as required, and Staff are not providing medication as prescribed the following was found. On 12/09/2024 When ED was interviewed the LPA found the following. ED states that when they came in they felt like the facility was not lacking in sanitation and cleanliness in their opinion. However ED did acknowledge that prior to their on boarding the center elevator was down for about a month and a half. The ED states that they just discovered that one of the fireplaces is not operational last week when putting up Christmas decorations. ED states that they are aware of the dryers and washers being out of service but they are not aware of how long they have been out of service. ED stated that they are actively trying to get new carpets but will not know if it is approved by upper management. ED states that the prior Health and Wellness Director (HWD) would change the residents needs and services and that they would receive the care but that the families were not aware of the cost associated with the care. The ED states that because of the discrepancy they have reimbursed credits. ED states that HWD resigned when confronted with the discrepancy. It was also found before the HWD resigned that reports were not being reported as required. ED states that there were instances where residents care plan did not match the care they needed or did not require.

On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R1 MAR where medication was marked as administered however R1 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight.


Report continues on LIC9099-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20241203085000
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: 05/14/2025
NARRATIVE
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On 5/14/2025 LPA also tested the call buttons in memory care and found that the systems to notify staff of calls are not properly working. Memory care coordinator states that they are actively working towards a solution and are currently training staff on how to ensure residents safety without call buttons. Throughout all visits the LPA also observed that the communities carpet is in disrepair with rips throughout the community. The carpet observed in disrepair is only located throughout the assisted living side of the community.

Based on interviews, record reviews, and observations the allegations Facility is in disrepair, Staff are not following the residents care plan, Facility does not send incident reports as required, and Staff are not providing medication as prescribed is SUBSTANTIATED.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20241203085000
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
Section Cited
CCR
87307(d)(2)
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(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair...

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Elavator, fireplace, and washing utilities have been repaired or replaced. ED is currently developing a solution for replacment of call buttons that are in disrepair along with their notification counterparts. By POC ED agrees to have an order for all carpets to be replaced in assisted living and send a copy of the work order to ccld. LPA will return to inspect when new carpets are installed.
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Based on observations and interview the facility did not comply with the following by the elevator, fireplace, and other utilities being in disrepair which poses a potential safety and personal rights violation to residents in care.
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Type B
05/14/2025
Section Cited
CCR
87211(a)
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(a) Each licensee shall furnish ... reports...but not limited to, the following:

this requirement was not met as evidence by:
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ED states that previous HWD has resigned and new staff has been adequately trained on procedure
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Based on interview the facility did not comply with the following by not reporting incidents as required which poses a potential safety and personal rights violation to residents 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20241203085000
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2025
Section Cited
CCR
87465(a)
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(a) A plan ...by compliance with the following:

this requirement was not met as evidence by:
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By POC facility agrees to review the regulation and notify CCLD
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Based on record review the facility did not comply with the following by having an inaccurate MAR which put into question the validity of the entries which poses a potential safety and personal rights violation to residents in care.
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Type B
05/14/2025
Section Cited
CCR
87463(f)
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(f) The licensee shall .., communicate ... any significant change ...Documentation...shall be added to the resident’s record.

this requirement was not met as evidence by:
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HWD has since resigned and new staff has been trained appropriately.
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Based on record review and interview the facility did not comply with the following by previous HWD updating residents care plan and not notifying the appropriate parties and not providing the care specified which poses a potential personal rights violation to residents 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
12/03/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20241203085000

FACILITY NAME:IVY PARK AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:MORGAN, OREISHAFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:162CENSUS: 146DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Orisha MorganTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
The facility is not clean and sanitary
The facility does not provide adequate care for its residents
Facility has insufficient staff to provide adequate care for residents
Facility staff are administering controlled substence innaproriately
INVESTIGATION FINDINGS:
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On 5/14/2025 at 2:30PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit.

During the investigation, LPA conducted interviews, toured facility, and reviewed files. On 12/09/2024 LPA reviewed interviewed ED. On 4/23/2025 LPA interviewed S1 and S2. LPA also obtained corespondences regarding varios residents.

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: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20241203085000
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: 05/14/2025
NARRATIVE
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On the allegations The facility is not clean and sanitary, The facility does not provide adequate care for its residents, Facility has insufficient staff to provide adequate care for residents, Facility staff are administering controlled substance inappropriately the following was found: LPA visited the facility on multiple occasions and observed it to be clean and sanitary. LPA also interviews ED who corroborated the cleanliness of the facility. During all visits LPA observed adequate staffing and observed enough staff had been scheduled ED also stated that they have been actively hiring additional staff. LPA interviewed R2, R3, and R4 who all stated that they were happy with the facility and the level of care being provided. Due to the reporting party not providing additional information in relation to the complaint allegations LPA was unable to speak with specific residents relating to the allegations and had to do a random selection of residents therefore the allegations The facility is not clean and sanitary, The facility does not provide adequate care for its residents, Facility has insufficient staff to provide adequate care for residents, Facility staff are administering controlled substance inappropriately is UNSUBSTANTIATED.

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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7