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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601148
Report Date: 06/05/2025
Date Signed: 06/05/2025 11:32:54 AM

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
03/14/2025 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20250314144621
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: DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alan Fox, Regional Operations SpecialistTIME COMPLETED:
11:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client's care needs not met by staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/5/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Regional Operations Specialist, Alan Fox. LPA toured the facility, interviewed residents, staff and outside parties, reviewed records and made observations during the course of the investigation.

Complaint alleges client (R1) care needs are not being met by staff regarding R1 being observed in poor condition. Upon interview with R1's responsible party (I1), witness (I2) and facility Executive Director (S1), it was explained that R1 had been transferred to the UCSF emergency room after an incident occurred during a scheduled medical appointment. R1 was transferred from the UCSF primary medical center, not from the residential care facility. Observed wounds were pre-existing and were being treated appropriately by the facility along with additional documented outside medical agency care.

Continued onto LIC9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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-20250314144621
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: 06/05/2025
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
Based upon review of R1’s physician’s report, R1 is cognitively able to determine their own medical and assistance needs. Interviews with residents (R1, R2), responsible party (I1) and witness (I2) indicated the facility is providing appropriate care and meeting resident needs with no concerns indicated.

A finding that the complaint allegation client's care needs not met by staff is 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. No deficiency cited.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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