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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 05/29/2025
Date Signed: 05/29/2025 01:57:24 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
01/24/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250124161752
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: 152DATE:
05/29/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Executive Director, Orisha MorganTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff mismanaged residents’ medications.
Facility staff failed to notify resident and responsible party
Staff did not respond to resident's call button in a timely manner
INVESTIGATION FINDINGS:
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On 5/29/2025 at 9:20AM, 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 interviewed R2, R3, and R4.

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: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
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 5
Control Number 15-AS-20250124161752
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: 05/29/2025
NARRATIVE
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On the allegations Staff mismanaged residents’ medications, Facility staff failed to notify resident and responsible party, Staff did not respond to resident's call button in a timely manner the following was found:

On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R2 MAR where medication was marked as administered however R2 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.

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.On 5/29/2025 LPA tested the call buttons in the room which was occupied by R1. LPA found during the test that the call button in the bathroom was not operational. The ED was not aware that the call button did not work and did not have a work order for it to be serviced.

On 12/09/2024 LPA reviewed interviewed ED. 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.

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

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250124161752
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: 05/29/2025
NARRATIVE
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Pg 3

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.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20250124161752
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: 05/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2025
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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Under Appeal
Type B
06/05/2025
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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By POC ED agrees to have an order for replacment of call buttons that are in disrepair along with their notification counterparts. LPA will return to inspect the call buttons when relaced
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Based on observations and interview the facility did not comply with the following by the call buttons being in disrepair 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: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20250124161752
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: 05/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
05/29/2025
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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System has been updated and staff was retrained on how to adequetly document medications.
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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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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: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5