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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201317
Report Date: 08/02/2024
Date Signed: 08/02/2024 10:58:30 AM


Document Has Been Signed on 08/02/2024 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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:
08/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Linda NguyenTIME COMPLETED:
11:15 AM
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On 8/2/2024 at 9:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced for a case management visit concerning the 7/28/2024 incident with Resident R1 who eloped from the facility. Upon entering the facility, the LPA stated the purpose of visit to Executive Director (ED) Linda Nguyen.

During the visit, the LPA interviewed the ED and Health Service Director (HSD) Sarah Summers about the incident. The HSD explained what had occurred on 7/28/2024 when R1 eloped. R1 moved into the facility on 7/17/2024 into Assisted Living. The HSD stated that though R1 wore a WanderGuard and the staff responded quickly when notified that R1 had left the building, R1 is a very fast walker and had left before staff arrived.

In their post incident follow up, family member F1 stated that R1 had been "triggered" to elope due to family issues. Because this event revealed the potential risk of R1 eloping again in the future, on 8/5/2024, R1 will be moving into a memory care unit in a different facility.

No citations issued during this visit.

Exit interview was conducted with the ED. A copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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