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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202621
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:14:15 PM


Document Has Been Signed on 02/17/2022 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:IVY PARK AT SAN JOSEFACILITY NUMBER:
435202621
ADMINISTRATOR:MICHAEL FOUNTAINFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE RDTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:140CENSUS: DATE:
02/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sarah PostTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) arrived unannounced to conduct a case management visit and met with Executive Director (ED) Sarah Post. The purpose of the visit was to obtain additional information from an elopement incident report received on 02/11/2022 involving resident (R1).

During visit, LPA interviewed ED and obtained R1's staff assessment sheet.

R1 was recently admitted to the facility and was residing in the Assisted Living unit. Staff was notified by R1's family member during a visit that R1 was not in the room. Staff had notified the ED and Health Service Director immediately and facility's elopement procedures were taken place. Approximately twenty minutes later, R1 was found walking outside of the community by R1's family member and staff member. R1 was immediately brought back to the community and was assessed for injuries. No injuries were noted. Based on record review, resident is unable to leave the facility unassisted.

Prior to admission resident was assessed for capabilities, special needs, and behaviors. R1's behaviors listed wandering and exit seeking behavior. R1's individual care plan did not include the facility's plan of action to indicate how the resident's behaviors will be met.

Deficiencies are being cited based on interview and record review conducted accordance with the California Code of Regulations, Title 22. See LIC809D.

An exit interview was conducted and Plan of Correction were developed and reviewed with the ED. A copy of this report and appeal rights were provided with Executive Director, Sarah Post.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/17/2022 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: IVY PARK AT SAN JOSE
FACILITY NUMBER: 435202621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited

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(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates: (4)Without violating Section 87468, Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility.

This requirement is not met as evidence by:
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Based on interview and record review, the licensee did not ensure facility staff attempted to redirect resident (R1) from leaving the facility unassisted which poses an immediate Health and Safety risk to persons in care.
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LPA obtained facility's in-service training on elopement / missing resident.
Type B
02/24/2022
Section Cited

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(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs...(2)… if an initial appraisal or any reappraisal identifies an individual resident service need which is not being met … the licensee … shall develop a plan of action which shall include: (A)Objectives, within a time frame, which relate to the resident's problems and/or unmet needs. (B) Plans for meeting the objectives.

This requirement is not met as evidence by:
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Based on observation, interview, and record review the licensee did not ensure to develop a plan of action to how resident's (R1) problems will be met during assessment which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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