385601148-5-2-2025-14-AS-KHOS-DGUKT8-20250520081044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601148
Report Date: 05/02/2025
Date Signed: 05/02/2025 03:37:45 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
02/21/2025 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 14-AS-20250221141055

FACILITY NAME:	IVY AT GOLDEN GATE, THE		FACILITY NUMBER:	385601148
ADMINISTRATOR:	RAUKHMAN, KATHERINE		FACILITY TYPE:	740
ADDRESS:	1601 19TH AVENUE		TELEPHONE:	(415) 664-6264
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	168	CENSUS: 126	DATE:	05/02/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Katherine Raukhman, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not ensure that resident was dispensed their medication as prescribed
Staff did not refill resident’s medication prescription in a timely manner

INVESTIGATION FINDINGS:

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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 ensure that resident was dispensed their medication as prescribed for resident (R1). Upon interviews with staff and information provided by Reporting Party, LPA found consistent information regarding staff observing resident R1 to be asleep and unable to administer a (as needed/PRN) narcotic to R1 because of R1's observed status. In addition, staff did administer medication upon observation as needed when R1 had awoken later within the hour. Upon review of R1’s medication administration records, LPA was unable to find corroborating evidence supporting the allegation.

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)

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Control Number 14-AS-20250221141055

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

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Complaint also alleges a second medication for daily administration was not provided. Upon interviews with staff and a review of R1's medication records, LPA gathered information regarding medication delivery and orders. Facility staff (S2,S3,S4) statements were consistent, indicating that the medication was delivered but a physician order was not included. Staff stated they contacted R1's hospice agency multiple times by phone, requesting for the signed order. Lastly, the signed physician's order was eventually provided several days after the delivery for reconciliation, indicating potential delay in documentation being provided to the facility. R1 was provided the medication the following day of receiving the signed order. LPA determined that there is conflicting information and a lack of corroborating evidence towards the allegation.

Complaint alleges, staff did not refill resident’s medication prescription in a timely manner. Upon review of resident records it was found that R1 was prescribed a daily medication that assist with bowel movement. In addition, R1 is also prescribed a second medication that targets bowel movement, but only used as needed (PRN) when the primary daily medication is not effective after several days. Interview with Executive Director (S1) and review of R1's medication and hospice records indicated that the amount of PRN medication administered was within the total quantity of the PRN medication doses on supply. There is no other indication of R1's observed symptoms in either charting notes, hospice records or medication records that indicate R1's need for additional PRN nor indication of the facility not having sufficient supply on hand. LPA attempted to contact the hospice agency but was not able to gather statement.

A finding that the complaint allegations, staff did not ensure that resident was dispensed their medication as prescribed and staff did not refill resident’s medication prescription in a timely manner 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)

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