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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600430
Report Date: 05/10/2024
Date Signed: 05/10/2024 11:23:12 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
10/23/2023 and conducted by Evaluator John Calandra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231023135749
FACILITY NAME:IVY AT GOLDEN GATE, THEFACILITY NUMBER:
385600430
ADMINISTRATOR:KATHERINE RAUKHMANFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6264
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:0CENSUS: 120DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Katherine Raukhman, Executive Director TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not prevent memory care resident from eloping.
INVESTIGATION FINDINGS:
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On May 10, 2024, Licensing Program Analyst (LPA) John Calandra conducted a conclusionary complaint investigation at the facility and met with Katherine Raukhman. The purpose of the visit was to deliver conclusionary findings to the initial complaint investigation on October 31, 2023. LPA gathered information relevant to the above complaint allegation and interviewed staff. Regarding the allegation that staff allowed a resident to elope, it was found that there was at least one time that staff did not prevent a memory care resident from eloping. Without violating personal rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. Staff have failed to do this based on information gathered.

The Department has investigated the complaint allegation of a possible violation of a resident’s personal rights. We have found that the complaint allegation is substantiated. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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 4
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
10/23/2023 and conducted by Evaluator John Calandra
COMPLAINT CONTROL NUMBER: 14-AS-20231023135749

FACILITY NAME:IVY AT GOLDEN GATE, THEFACILITY NUMBER:
385600430
ADMINISTRATOR:KATHERINE RAUKHMANFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6264
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:0CENSUS: 120DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Katherine Raukhman, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
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9
Facility did not have care plan for resident.
Facility did not provide copy of admissions agreement to resident's responsible person.
INVESTIGATION FINDINGS:
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On May 10, 2024, Licensing Program Analyst (LPA) John Calandra conducted a conclusionary complaint investigation at the facility and met with Katherine Raukhman, Executive Director. The purpose of the visit was explained. LPA gathered information relevant to the above complaint allegations and reviewed records. Based on review of records, it was found that facility did provide the admissions agreement to resident's responsible party and had a care plan on file.

The Department has investigated the complaint allegations of possible violations of the admissions agreement. We have found that the complaint allegations are unfounded, meaning that the allegations are false, could not have happened and/or is without a reasonable basis.

This report is provided and reviewed with facility representative, and a copy of this report must be made available for public review upon request.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 14-AS-20231023135749
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 AT GOLDEN GATE, THE
FACILITY NUMBER: 385600430
VISIT DATE: 05/10/2024
NARRATIVE
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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 facility representative, and a copy of this report must be made available for public review upon request.

Appeal rights discussed and provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20231023135749
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 AT GOLDEN GATE, THE
FACILITY NUMBER: 385600430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/11/2024
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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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: the facility did not ensure basic services were being met; due to lack of supervision, R1 was able to elope, which poses an immediate health, safety and personal rights risk to residents.
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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: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4