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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201317
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:32:22 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
03/06/2025 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250306081749
FACILITY NAME:IVY PARK AT WALNUT CREEKFACILITY NUMBER:
079201317
ADMINISTRATOR:LINDA NGUYENFACILITY TYPE:
740
ADDRESS:2175 YGNACIO VALLEY ROADTELEPHONE:
(925) 932-3500
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:86CENSUS: 71DATE:
03/06/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director Linda NguyenTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure resident was allowed visitors while in care.
INVESTIGATION FINDINGS:
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On March 6, 2025, at 1:30 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced at the facility to investigate the allegation above. Upon entry into the facility, the LPA identified himself and stated the purpose of the visit to Executive Director (ED) Linda Nguyen.

The complaint alleges that staff did not ensure resident was allowed visitors while in care.
The LPA reviewed facility documentation. In an email from the ED, she stated that between February 15 and February 20, 2025, the facility put in guidelines for visitations with Resident R1 that allowed R1 to meet with any visitor only in common areas of the community and for a maximum of 20 minutes per visit. Those restrictions confirmed the allegation.

Continued on LIC 9099-C. . .
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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 3
Control Number 15-AS-20250306081749
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 WALNUT CREEK
FACILITY NUMBER: 079201317
VISIT DATE: 03/06/2025
NARRATIVE
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. . .Continued from LIC 9099

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED.

Deficiency is cited under the California Code of Regulations listed on LIC 9099-D. 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 with ED. Appeal Rights and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20250306081749
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 WALNUT CREEK
FACILITY NUMBER: 079201317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/13/2025
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in All Facilities (a) . . . have all of the following personal rights: (11) To have their visitors . . . during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.

This requirement was not met as evidenced by:
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Deficiency cleared before visit on February 20, 2025.
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Email from ED to ombudsperson dated February 26, 2025 stated the dates when restrictions on visitation rights had been implemented by the facility.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3