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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:10:49 PM


Document Has Been Signed on 08/28/2024 03:10 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



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: 141DATE:
08/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Fili Igafo, Executive DirectorTIME COMPLETED:
03:25 PM
NARRATIVE
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On 8/28/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of conducting a case management to follow up on a facility self-reported incident and was greeted by Executive Director, Fili Igafo. The incident occurring on 6/7/2024, involved morning staff observing a table that was blocking resident’s (R1) bedroom door. The incident was reported to CCLD by the facility and confirmed based on the report and staff interviews with LPA Calandra, that overnight caregiver staff (S1) intentionally placed table in front of R1’s door to prevent R1 from wandering. LPA Calandra previously gathered information on the incident and spoke with Executive Director on corrective actions. LPA Tobola was informed that the facility had conducted an internal investigation and terminated staff (S1).

Due to resident R1's door being obstructed intentionally by staff, the facility has failed to ensure residents room door were unobstructed and violated the personal rights of resident R1.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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Document Has Been Signed on 08/28/2024 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2024
Section Cited
CCR
87468.1(a)(6)

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Personal Rights of Residents in All Facilities - ..to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.
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Administrator has taken corrective action and terminated staff (S1). Deficiency cleared at the time of visit.
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This was not met as evidence by: Based on a review of facility Incident Report and interviews with LPA Calandra and Executive Director, it was found that staff (S1) was found and admitted to have placed a table in front of resident (R1) bedroom door, preventing R1 from leaving. This is a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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