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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 05:17:28 PM

Unsubstantiated


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
02/26/2025 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250226123111
FACILITY NAME:IVY PARK AT WALNUT CREEKFACILITY NUMBER:
079201317
ADMINISTRATOR:CASTRO, GILBERTFACILITY 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 utilizing medical devices.
Licensee did not obtain resident appraisal before admittance.
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 allegations 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 utilizing medical devices.
The LPA interviewed Witness W1, Resident R1, and the ED. The LPA reviewed documentation concerning R1's hearing and hearing aid. Based on the interview of R1 with no hearing aid, documentation concerning the hearing aid, and statements from the ED, R1 was admitted into the facility with no hearing aid and the use of a hearing aid is not required to communicate with R1. The data collected does not confirm the allegation.

Continued on LIC 9099-C. . .
Unsubstantiated
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 2
Control Number 15-AS-20250226123111
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 complaint alleges that Licensee did not obtain resident appraisal before admittance.
The LPA reviewed the preadmission appraisal of R1 and documentation from John Muir Medical Center dated November 13, 2024 stating that R1 does not have the capacity to make informed medical decisions. The data collected does not confirm the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove it; therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted with ED and a copy of this report was provided.
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: 2 of 2