385601148-9-6-2024-14-AS-AMEN-D96LU8-20240916090332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601148
Report Date: 09/06/2024
Date Signed: 09/06/2024 12:08:25 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
01/29/2024 and conducted by Evaluator John Calandra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240129162503

FACILITY NAME:	IVY AT GOLDEN GATE, THE		FACILITY NUMBER:	385601148
ADMINISTRATOR:	RAUKHMAN, KATHERINE		FACILITY TYPE:	740
ADDRESS:	1601 19TH AVENUE		TELEPHONE:	(415) 664-6254
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	168	CENSUS: 126	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Katherine Raukhman, Executive Director		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility staff failed to provide safe, healthful and comfortable accommodations.
Facility failed to provided tray service when resident is ill.
Facility staff failed to provide medication according to the physician's directions.
Facility staff failed to accord dignity in their personal relationships with other persons.
Facility Staff did not clean and disinfect COVID positive resident room.

INVESTIGATION FINDINGS:

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On September 6, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for a complaint opened on February 7, 2024. LPA Calandra was greeted by Katherine Raukhman, Executive Director and explained the purpose of the visit.

During the initial visit, LPA gathered information including relevant records and conducted staff interviews. Based on information gathered, the facility provided a work order for carpet cleaning service due to the need for maintenance services because a section of the resident’s room was found to be unsanitary and unclean due to the resident’s temporary illness. The facility was notified by responsible party during a visit that the room needed to be cleaned again on January 18, 2024 and the facility took action on that date.

Regarding allegation of meals not being provided to residents who have to isolate in their rooms, there was an occasion where a resident was ill and required to be isolated to his room for approximately five days. If a resident is isolating in their room, the facility will provide and deliver the meals to resident’s room. This resident has a private caretaker that would pick up the meals and bring them to the room. Based on information gathered, there appears to have been a misunderstanding regarding who would retrieve the meals because of this situation. Regarding the medication issue, the resident had medication that was prescribed and the doctors order on file specified medication be given at particular times of day. Furthermore, based on the medication package instructions, which the facility was directed to follow by the physician the medication was provided at those particular times of day.

Unsubstantiated

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: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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-20240129162503

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: 09/06/2024

NARRATIVE

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Regarding the allegation that facility staff failed to accord dignity in their personal relationships with other persons, the reporting party alleges that a family member was visiting resident and she was spoken to in a manner that she feels was disrespectful. Information was obtained from both sides and there is not enough specific information to determine if this happened. LPA interviewed several staff and they stated they are unaware of any incidents regarding any person being spoken to in a disrespectful manner.

Allegation regarding facility not cleaning and disinfecting room due to resident having COVID, the responsible party alleges that “staff felt it was dangerous and possibly be exposed” to COVID. Facility stated that staff can clean the room as long as they are wearing the required PPE and continue as their normal schedule. Facility policy of cleaning rooms when a resident has COVID is that "the Care Provider will disinfect the apartment during the shift by replacing tissue, disposable bags when full, wiping off the surfaces in the apartment and bathroom with disinfectant wipes or by cleaning with paper towels and the spray bottle of germicidal agent."

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted. This report was reviewed with Katherine Raukhman, Executive Director and a copy of the report left at the facility.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

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