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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 04/25/2023
Date Signed: 04/25/2023 01:57:45 PM


Document Has Been Signed on 04/25/2023 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:IVY PARK AT CATHEDRAL HILLFACILITY NUMBER:
385600429
ADMINISTRATOR:JEFF SUMABATFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 67DATE:
04/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Jeff Sumabat; Memory Care Director, Joy QuiletTIME COMPLETED:
02:10 PM
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On 4/25/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. LPA met with Memory Care Director and administrator and explained the purpose of the visit.

On 4/12/2023, facility report an abuse allegation that staff #1 (S1) witnessed staff #2 (S2) of blocking resident #1 (R1) from leaving one of the pods and punching R1's abdominal area with small pink dumbbells. S1 reported that this incident happened on 4/4/2023 but S1 did not reported it to the facility director until 4/12/2023.

Once the facility was notified of the incident, the facility placed the alleged abuser on administrative leave pending investigation, reported the incident to R1's responsible party, CCL and the Ombudsman, started daily monitoring for R1 and provided in-services.

No deficient is cited today as this incident requires further follow-up and the facility has not completed its investigation.


This report is reviewed and discussed with the administrator, memory care director.


SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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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