275202358-11-14-2023-24-AS-BCHN-CYP3D7-20231219170901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202358
Report Date: 11/09/2023
Date Signed: 11/14/2023 11:29:20 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2023 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230913101615

FACILITY NAME:	IVY PARK AT MONTEREY		FACILITY NUMBER:	275202358
ADMINISTRATOR:	SHEARER, KELLIE D		FACILITY TYPE:	740
ADDRESS:	1110 CASS ST		TELEPHONE:	(949) 744-5200
CITY:	MONTEREY	STATE: CA	ZIP CODE:	93940
CAPACITY:	112	CENSUS: 89	DATE:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	11:11 AM
MET WITH:	Administrator, Kellie Shearer		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff does not provide adequate food service.
Staff does not adequately clean and sanitize resident's room.
Staff does not provide resident with clean clothing.
Staff does not label resident's hygiene products.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/09/23 Licensing Program Analyst (LPA) V Gorban visited the facility stated above to deliver findings. LPA met with Administrator (AD) Kellie Shearer and explained the purpose of the visit. LPA toured the facility inside and out, observed residents in care and discussed findings to allegations with AD.

Allegation: Staff does not provide adequate food service.

During this investigation LPA interviewed staff, residents, and reviewed facility files. During this investigation LPA observed residents during lunch, interviewed residents with family members, and reviewed files. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Report continues on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 24-AS-20230913101615

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: IVY PARK AT MONTEREY	FACILITY NUMBER: 275202358
	VISIT DATE: 11/09/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff does not adequately clean and sanitize resident's room.

During this investigation LPA toured random residents’ rooms and bathrooms. LPA also interviewed facility administrator, staff, residents and other individuals participating in residents’ care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff does not provide resident with clean clothing.

During this investigation LPA reviewed facility files and interviewed residents, staff, and facility Administrator. Per admission agreement facility does provide laundry services to residents once a week. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff does not label resident's hygiene products.

During the investigation LPA interviewed staff, residents, and administrator. Investigation revealed that facility follow health and infection prevention steps to avoid residents use each other personal hygiene items. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited during this visit.

Exit interview conducted, report signed and copy of this report provided to administrator for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2