415601177-3-11-2026-14-AS-ACON-DSAMEC-20260318093231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601177
Report Date: 03/11/2026
Date Signed: 03/11/2026 01:57:41 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
01/12/2026 and conducted by Evaluator Komal Curley

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20260112113350

FACILITY NAME:	IVY PARK OF BELMONT		FACILITY NUMBER:	415601177
ADMINISTRATOR:	ANNE BUERHAUS		FACILITY TYPE:	740
ADDRESS:	1010 ALAMEDA DE LAS PULGAS		TELEPHONE:	(650) 508-0400
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	117	CENSUS: 79	DATE:	03/11/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Anne Buerhaus		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff admitted residents into the facility with incomplete physician reports
Staff did not ensure residents medications were dispensed as prescribed
Staff did not ensure care and supervision was provided to resident resulting in an elopement from the facility

INVESTIGATION FINDINGS:

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On March 11, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit.

Regarding the allegation, staff admitted residents into the facility with incomplete physician reports, according to the reporting party, the facility admitted Resident 1 (R1) and Resident 2 (R2) to the facility without ensuring the LIC602 Physician’s Reports were completed.

During the investigation, LPA reviewed R1 and R2’s file. Based on the admission agreement reviewed for both residents, the admission agreement was signed on 12/30/25 and R1 and R2 physically moved into the facility on 1/6/25. Based on R1 and R2’s physician’s report, both physician’s reports were completed, signed and dated on 9/5/25. (continue to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

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-20260112113350

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 PARK OF BELMONT	FACILITY NUMBER: 415601177
	VISIT DATE: 03/11/2026

NARRATIVE

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Regarding the allegation, staff did not ensure residents medications were dispensed as prescribed, according to the reporting party, because R1 and R2's physician's report was not completed, the administrator indicated that the staff have not been giving R1 and R2 any of their medication.

During the investigation, LPA interviewed staff, reviewed charting notes and reviewed fax documentation that was sent to R1 and R2's physician. Based on charting notes reviewed notes on 1/6/26, the facility was awaiting a signed medication and notified R1 and R2's responsible party. Facility staff notified R1 and R2's responsible party to assist with medication administrator until the medication list was signed. According to staff interviewed and fax documentation, the facility sent multiple faxes to R1 and R2's physician to sign R1 and R2's current medication list so medication can be administered by the facility. Additional fax sheets dated 1/9/26-1/12/26 sent to the physician reports that R1 and R2 missed their medication because there were missing medication, missing a signed medication list and needed reconciliation.

Regarding the allegation, staff did not ensure care and supervision was provided to resident resulting in an elopement from the facility, according to the reporting party, on 1/10/26, R1 eloped out of the memory care unit and was found at the grocery store and brought back to the facility.

During the investigation, LPA interviewed staff and reviewed documents. According to staff interviewed and charting notes reviewed, R1 did not elope from the facility on 1/10/26. On 1/10/26, R1 attempted to elope from the facility, however he/she was found on the facility premises at the back gate and was redirected back to the facility.

Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

LIC9099 (FAS) - (06/04)

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