385600429-5-14-2024-14-AS-AMEN-D5QLPF-20240529085548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:44:18 AM

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
05/09/2024 and conducted by Evaluator John Calandra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240509102757

FACILITY NAME:	IVY PARK AT CATHEDRAL HILL		FACILITY NUMBER:	385600429
ADMINISTRATOR:	ELLA FRICK		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS: 147	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Fili Igafo, Executive Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not ensure emergency services were contacted in a timely manner

INVESTIGATION FINDINGS:

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On May 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:00 AM to conduct an unnanounced Complaint Investigation. The purpose of the visit was to open a complaint received on May 9, 2024 and deliver conclusionary findings. LPA Calandra was greeted by Executive Director, Fili Igafo, and explained the purpose of the visit. LPA Calandra gathered relevant information to the above allegation, interviewed staff and collected documents.

Regarding the allegation of a violation of resident’s personal right to medical services, it was found that there was at least one time that staff did not contact emergency personnel in a timely manner. Residents have medical and dental needs, and the Licensee shall provide assistance in meeting those necessary medical and dental needs. Staff have failed to do this based on information gathered.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20240509102757

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: 05/14/2024

NARRATIVE

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The Department has investigated the complaint allegation that staff did not contact emergency personnel in a timely manner. We have found that the complaint allegation is substantiated. Based on the investigation, the preponderance of evidence standard has been met.

The deficiency cited on the following page is in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8:

This report is provided and reviewed with Executive Director, Fili Igafo, and a copy of this report must be made available for public review upon request.

Appeal rights discussed and provided.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20240509102757

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: 05/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/15/2024 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465(a)(2): Incidental Medical and Dental Care - (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87465(a)(2). Facility will develop a plan to ensure that residents' medical and dental needs are met without delay. That plan will be received by CCLD to address deficiency.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by facility staff did not call 911 immediately for R1 but instead waited to tell S1 when S1 started their shift. 911 was alerted approximately 2 hours after R1 was found unresponsive. Medical personnel were not contacted in a timely manner.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

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