<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601148
Report Date: 05/02/2025
Date Signed: 05/02/2025 03:39:09 PM

Unsubstantiated


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
02/12/2025 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20250212155932
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: 126DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Katherine Raukhman, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not distribute resident's medication as prescribed
Staff did not maintain current resident records
Staff are not communicating with responsible party regarding resident's care service
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/2/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Katherine Rauhkman. LPA interviewed staff, reviewed resident records and made observations during the course of the investigation.

Complaint alleges staff did not distribute resident's (R1) medication as prescribed. LPA conducted a spot review of R1’s medication administration records and did not identify any medication not properly administered. Upon additional interview with Reporting Party, LPA received contradicting information to the initial complaint intake statement. LPA was not provided specific information on medication errors by Reporting Party.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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 2
Control Number 14-AS-20250212155932
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: 05/02/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff did not maintain current resident records. LPA conducted a review of R1’s records and found that the facility had maintained R1’s medication records. Upon additional interview with Reporting Party, LPA received contradicting information to the initial complaint intake statement. LPA was not provided specific information on medication record issues by Reporting Party. Upon review of R1's medication records, LPA found that R1's medication administering records were on file.

Staff are not communicating with responsible party regarding resident's care service. Upon interview with Executive Director, and corresponding documented communication with R1’s, responsible party, it was determined that there was documented communication from the facility regarding R1's care service. From documentation gathered, LPA found contradicting information in relation to the allegation.

A finding that the complaint allegations, staff did not distribute resident's medication as prescribed, staff did not maintain current resident records and staff are not communicating with responsible party regarding resident's care service are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2