079201317-7-2-2025-15-AS-KHOS-DJMKMN-20250716080150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201317
Report Date: 07/02/2025
Date Signed: 07/02/2025 05:06:46 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
07/02/2025 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20250702094439

FACILITY NAME:	IVY PARK AT WALNUT CREEK		FACILITY NUMBER:	079201317
ADMINISTRATOR:	LINDA NGUYEN		FACILITY TYPE:	740
ADDRESS:	2175 YGNACIO VALLEY ROAD		TELEPHONE:	(925) 932-3500
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	86	CENSUS: 74	DATE:	07/02/2025
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Executive Director Linda Nguyen		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not properly assess a resident
Staff did not prevent a resident from wandering from the facility
Staff did not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

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On 7/02/2025, at 2:45 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to investigate the allegations above. Upon arrival, the LPA informed Executive Director (ED) Linda Nguyen of the purpose of the visit.

The complaint alleges staff did not properly assess Resident R1.
The LPA interviewed Witness W1 by telephone. At the facility, the LPA interviewed the ED and reviewed R1's file, including the Physician's Report, Preplacement Appraisal, and the 1/31/2025 incident investigation report. The Physician's Report, dated 1/3/2025, indicated no Inappropriate Behavior, no Aggressive Behavior, no Wandering Behavior, and no Exit Seeking Behavior. During the 1/31/2025 incident, R1 demonstrated all those behaviors. The preplacement appraisal was based on information collected and observations made in an environment and from people R1 knew and trusted. Like the Physician's Report, it was only an indicator and not a predictor of R1's behavior in an unfamiliar place and with unfamiliar people. The data collected and analyzed by the LPA shows that the staff did properly assess R1, which 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: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250702094439

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: 07/02/2025

NARRATIVE

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. . . Continued from LIC 9099

The complaint alleges staff did not prevent Resident R1 from wandering from the facility.
The LPA interviewed Witness W1 by telephone. At the facility, the LPA interviewed the ED and reviewed R1's file, including the Physician's Report, Preplacement Appraisal, and the 1/31/2025 incident investigation report. When R1 wandered out of his room in the middle of the night, it was his right to do so in Assisted Living. When R1 wandered outside of the facility, he was never left alone. The staff acted appropriately with R1 when he spoke to them inappropriately and threatened them with his cane and walker. The staff did what they were supposed to do by escorting him and redirecting him from the outside at the back to the inside at the front of the building. The data collected and analyzed by the LPA shows that the staff did prevent R1 from wandering from the facility, which does not confirm the allegation.

The complaint alleges staff did not provide adequate care and supervision to Resident R1.
The LPA interviewed Witness W1 by telephone. At the facility, the LPA interviewed the ED and reviewed R1's file, including the Physician's Report, Preplacement Appraisal, and the 1/31/2025 incident investigation report. When R1 wandered outside of the facility, he was never left alone. The data collected and analyzed by the LPA shows that the staff did provide adequate care and supervision to R1, which does not confirm the allegation.

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

Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

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