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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601148
Report Date: 12/04/2024
Date Signed: 12/04/2024 11:53:52 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
09/05/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20240905102251
FACILITY NAME:IVY AT GOLDEN GATE, THEFACILITY NUMBER:
385601148
ADMINISTRATOR:RAUKHMAN, KATHERINEFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6264
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:168CENSUS: 125DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Katherine Raukhman, Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility did not issue refund
INVESTIGATION FINDINGS:
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On 12/4/2024, Licensing Program Analyst (LPA), Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Katherine Raukhman. LPA Interviewed staff, outside parties and reviewed resident records during the course of the investigation.

Complaint alleges facility did not issue refund regarding resident (R1). Upon interview with staff (S1) and outside parties (I1) it was found that resident R1 had been moved out of the facility on 7/13/2024 with all remaining personal property removed by 7/27/2024. Based upon documents gathered, LPA found that R1's responsible party had submitted a written notice on 7/1/2024, to terminate agreement (30) days prior. Based upon R1's admission agreement it is indicated that upon self-termination, "you will continue to be responsible for all fees and charges accruing under this Agreement until the later of the expiration of the thirty (30) day period or you have vacated your Residence..".

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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 3
Control Number 14-AS-20240905102251
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: 385601148
VISIT DATE: 12/04/2024
NARRATIVE
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The admissions agreement regarding refunds continues indicating, "within twenty-one (21) days after the Residence has been vacated, your property has been removed from the Residence, and the Residence has been restored to its original clean condition, we will pay you a refund equal to any unused portion of your final Monthly Fee and Level of Care Fee..".

Based upon interviews with staff (S2) it was found that the facility had refunded the level of care fees to R1 but had not yet refunded the monthly fees. It was found that R1's belongings had been moved out of the facility by 7/27/2024 but had not been fully refunded including the monthly fees until 10/9/2024 which goes against R1's admissions agreement.

Allegation, facility did not issue refund is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20240905102251
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: 385601148
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2024
Section Cited
HSC
1569.625(c)
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H&S 1569.625 - A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Executive Director and Business Office Director had determined correct refund amount accounting for R1's final move out date and both care and monthly fee's owed. LPA was provided copy of corrected refund amount to R1/responsible party.
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This was not met as evidence by: Based upon review of R1's admissions agreement, it is indicated that R1 is to be refunded within (21) days for any level of care and monthly fees upon move out and removal of all personal property. It was found that R1's belongings were moved by 7/27/2024 but not provided a full refund of fees until 10/9/2024. This serves as a potential personal rights risk to resident in care.
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Deficiency cleared at time of visit.
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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: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3