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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 08/09/2024
Date Signed: 08/09/2024 03:36:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator John Calandra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240305161257
FACILITY NAME:IVY PARK AT CATHEDRAL HILLFACILITY NUMBER:
385600429
ADMINISTRATOR:ELLA FRICKFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 137DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tam Nguyen, Maintenance Director and Fili Igafo, Executive Director TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident falling.
Staff did not respond to resident's call button in a timely manner.
INVESTIGATION FINDINGS:
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On August 9, 2024, Licensing Program Analysts(LPAs) John Calandra and Dominic Tobola, arrived at the facility at 9:20 AM to deliver findings for a complaint opened on March 12, 2024. LPAs Calandra and Tobola, were greeted by Tam Nguyen, Maintenance Director and explained the puprose of the visit. Fili Igafo, Executive Director arrived later during the visit.

Regarding the allegation, that staff did not provide adequate supervision resulting in resident falling, the department interviewed multiple staff. Through these interviews, it was found that staff had knowledge of other staff who were preoccupied with other activities during working hours and not attending to resident’s needs. Furthermore, the LPAs learned that the there is a lapse in communication amongst staff resulting in staff, not being able to provide adequate care and supervision to persons in care. Therefore, the preponderance of evidence standard has been met and this allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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 5
Control Number 14-AS-20240305161257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IVY PARK AT CATHEDRAL HILL
FACILITY NUMBER: 385600429
VISIT DATE: 08/09/2024
NARRATIVE
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Regarding the allegation, that staff did not respond to resident’s call button in a timely manner, the Department found through a review of the call button response log that on several occasions, facility staff have taken up to a total of 289 minutes to respond to call buttons. Furthermore, the LPAs learned that within the last 2 weeks, there have been a total of 16 residents who waited more than 30 minutes for assistance. Regarding this allegation, the preponderance of evidence has been met, and the allegation is SUBSTANTIATED.

The Department has investigated the above allegations of a possible violation of a resident’s personal rights. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegations are determined to be SUBSTANTIATED. The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8, Article 7: Personnel Requirements-General.

An exit interview was conducted. This report was reviewed with Fili Igafo, Executive Director and a copy of the report along with Appeal Rights were left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator John Calandra
COMPLAINT CONTROL NUMBER: 14-AS-20240305161257

FACILITY NAME:IVY PARK AT CATHEDRAL HILLFACILITY NUMBER:
385600429
ADMINISTRATOR:ELLA FRICKFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 137DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tam Nguyen, Maintenance Director and Fili Igafo, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident was left on floor for an extended period of time.
Staff did not observe resident's change of health conditions.
Staff did not reassess resident's care plan.
INVESTIGATION FINDINGS:
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On August 9, 2024, Licensing Program Analysts(LPAs) John Calandra and Dominic Tobola arrived at the facility to deliver findings for a complaint received on March 15, 2024. LPAs Calandra and Tobola were greeted by Executive Director, Fili Igafo and explained the purpose of the visit.

Regarding the allegation that staff did not observe resident’s change of health conditions, the department reviewed R1’s files. These files indicated that the facility observed R1 needing more assistance with activities of daily living and being at greater risk for falling and injuring oneself. Regarding the allegation that staff did not reassess resident’s care plan, the department reviewed R1’s files and found that two reassessments had been completed and implemented by the facility. Regarding this allegation, the preponderance of evidence standard has not been met and therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20240305161257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IVY PARK AT CATHEDRAL HILL
FACILITY NUMBER: 385600429
VISIT DATE: 08/09/2024
NARRATIVE
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Regarding the allegation, that the resident was left on the floor for an extended period of time, LPAs interviewed staff and asked but were not able to procure a copy of the call button response times. Due to a lack of evidence, this allegation is UNSUBSTANTIATED.

The department has investigated the above allegations that staff did not observe resident’s change of health conditions or reassess resident’s care plan. The allegations are UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted. This report was reviewed with Fili Igafo, Executive Director and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20240305161257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: IVY PARK AT CATHEDRAL HILL
FACILITY NUMBER: 385600429
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/10/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..(2) To be accorded safe,..
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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This requirement is not met as evidenced by record review and interview of Executive Director, which revealed that 16 out of 137 clients waited in some cases more than 289 minutes for care, which is an immediate health and safety risk to persons in care.
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Deficiency Dismissed
Type B
08/23/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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This requirement is not met as evidenced by observation and interview of staff, which showed that multiple facility staff are not competent to provide the services necessary to meet resident needs.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5