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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 10/13/2025
Date Signed: 12/23/2025 12:21:53 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
07/11/2025 and conducted by Evaluator John Calandra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250711142309
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: 157DATE:
10/13/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Chris Schuster, Executive Director/Administrator TIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Lack of supervision resulted in resident falling and sustaining injuries.
Staff are not reporting incidents involving residents as necessary.
INVESTIGATION FINDINGS:
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*****This is an amended version of the original report dated 10/13/2025, as a result of supervisory review*******

On 10/13/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint. LPA Calandra was greeted by Chris Schuster, Administrator and Executive Director and explained the purpose of the visit.

Complaint alleged that lack of supervision resulted in R1 falling and sustaining injuries. Since their admission in 2024, R1 fell over ten times at the facility resulting in R1 sustaining serious injuries such as fracture of a body part. Based on interviews, R1’s health had declined more significantly over the last few months. While a fall risk assessment had been completed by staff, R1 did not have a fall prevention plan in place. Based on interviews, staff were to conduct safety checks every 2 to 3 hours but no documentation of checks being conducted could be provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
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 4
Control Number 14-AS-20250711142309
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: 10/13/2025
NARRATIVE
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Complaint also alleged that facility staff are not reporting incidents involving residents as necessary. Based on interview and document review, there were several occasions in which R1 fell but the Licensee did not complete a written report within 7 days of the occurrence of the event for 9 out of the 10 falls.

Based on information reported by and obtained from facility staff and witnesses, these allegation is substantiated. The preponderance of evidence standard has been met.



Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An immediate civil penalty of $500.00 was issued and a copy of the LIC 421IM was given to Chris Schuster, Administrator/Executive Director. At the time of the complaint inspection on 12/23/2025, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Facility representative signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421IM.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20250711142309
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: 10/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/20/2025
Section Cited
CCR
87466
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87466: Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided when such observation reveals unmet needs.

This requirement was not met as evidenced by:
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Licensee will reevaluate the resident and put an appropriate plan in place. Licensee will also conduct additional training and send list of attendees and content of training to the Department by the POC due date. Licensee will also ensure all safety checks are documented.
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Based on interviews, the Licensee did not ensure that R1 was provided with appropriate assistance after the Licensee observed them falling on multiple occasions which is an immediate health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 14-AS-20250711142309
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: 10/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/20/2025
Section Cited
CCR
87211(a)(1)
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87211(a)(1): Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events.

This requirement is not met as evidenced by:
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Licensee will send an incident report for any fall. Licensee will work with Regional Director of Clinical Services and will ensure that all staff understand Licensing regulations and facility's internal policies.
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Based on document review, Licensee did not submit a written report to the Department for each fall occurrence of R1, which is a potential health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4