019200755-6-12-2024-15-AS-KHOS-D6JRCC-20240624125405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 06/12/2024
Date Signed: 06/12/2024 05:27:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/03/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240603125527

FACILITY NAME:	IVY PARK AT OAKLAND HILLS		FACILITY NUMBER:	019200755
ADMINISTRATOR:	CAGULADA, DILLON R		FACILITY TYPE:	740
ADDRESS:	11889 SKYLINE BLVD		TELEPHONE:	(510) 531-7190
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94619
CAPACITY:	100	CENSUS: 60	DATE:	06/12/2024
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Yolanda Harrell/Executive Director		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Staff leave residents in soiled clothing/bedding/diapers for an extended period of time.

-Staff are not ensuring residents carpet is cleaned properly.

-Staff are not allowing resident to make phone calls.

INVESTIGATION FINDINGS:

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At 11:05 a.m., Licensing Program Analysts (LPAs) Alicia Delmundo and Ardalan Gharachorloo arrived unannounced to investigate the above allegations. LPAs met with Executive Director (ED) Yolanda Harrell, and informed the reason for visit. LPAs also met with Memory Care Director (MCD) Sarah Carlen.

LPAs obtained copies of resident roster and staff schedule. LPA reviewed residents files and conducted inspection. LPAs interviewed 7 staff, resident and 3 residents' family members (FM1, FM2 anf FM3).

Allegation: Staff leave residents in soiled clothing/bedding/diapers for an extended period of time.
Reporting party stated that resident (R1) lives in urine soaked clothing and R3 reeks in urine.

.....continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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-20240603125527

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT OAKLAND HILLS	FACILITY NUMBER: 019200755
	VISIT DATE: 06/12/2024

NARRATIVE

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Page 2

During investigation, LPAs conducted inspection with MCD. LPAs randomly selected 8 rooms including R1 and R3's rooms and observed all the rooms including the beddings clean. LPAs observed all the residents including those in the common areas wearing clean clothing. Family members (FM1, FM2, and FM3) all stated they never observed their family member (resident) in soiled clothing. The five staff interviewed stated residents are changed 3 times during the shift and as needed. Due to medical condition/diagnosis, LPAs were not able to obtain information from the 4 residents including R1 regarding the allegation.

Allegation: Staff are not ensuring residents carpet is cleaned properly.
It was alleged that R1's carpet is soaked with urine.
LPA conducted inspection and didn't observed nor smell urine in any of the rooms including that of R1's. Five staff interviewed stated residents rooms are cleaned once a week and as needed and when residents have accidents, they clean immediately.

FM1 stated observing R2's carpet soiled with feces but when brought to the attention of the staff, the staff cleaned immediately. FM3 stated when staff learned R3 was urinating in the carpet, the carpet was removed and replaced with laminate flooring.

Allegation: Staff are not allowing resident to make phone calls.
Reporting party stated hearing staff talking to each other and a staff saying she would not allow resident in Memory Care Unit to call because that resident will call 9-1-1. LPAs interviewed this resident who stated she's able to speak with her family members. Staff interviewed confirmed that when residents want to call, the Memory Care Unit has a land line and have residents binder available and they dial the number of the family member whom resident wants to call/speak with.

.....continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20240603125527

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT OAKLAND HILLS	FACILITY NUMBER: 019200755
	VISIT DATE: 06/12/2024

NARRATIVE

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Two of the three family members interviewed stated they don't call because they come and visit the residents regularly while the other one stated not having issue calling and talking to the resident.
Due to medical condition/diagnosis, LPAs were not able to obtain information from the 3 residents.

Based on all information gathered during investigation, the 3 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted, and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

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