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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202621
Report Date: 04/21/2022
Date Signed: 04/21/2022 05:11:40 PM


Document Has Been Signed on 04/21/2022 05:11 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:SARA POSTFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE RDTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:140CENSUS: 97DATE:
04/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Sara PostTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to conduct the pre-licensing visit for facility #435202847. LPA met with Administrator, Sara Post.

During today's visit, LPA reviewed six resident's centrally stored medication record to consist of three residents in assisted living and three residents in memory care. At 11:00 a.m., LPA arrived in the assisted living medication room to review three residents centrally stored medication. It was observed that the facility staff were unable to locate the centrally stored medication records for the month of March - April. LPA waited at the medication room until 11:35 a.m. and records were still not found. LPA decided to continue with the pre-licensing visit as the facility staff looked for the centrally stored medication records for the month of March - April.

At 01:25 p.m., LPA went back to the assisted living medication room and facility staff were able to locate the centrally stored medication records. LPA observed the records were not located in the resident's file. Facility staff stated there to be only one NOC shift staff to be verifying the centrally stored medications and filing the records in the resident's binder.

At 02:10 p.m., LPA entered the memory care medication room to review three residents centrally stored medication log. At 02:20 p.m., LPA and staff observed three bottles of medication that were not recorded on the centrally stored medication record. Staff stated resident was transferred from the assisted living section in which the assisted living staff would have been responsible to record the medications.

See LIC-809C for additional information.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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 3


Document Has Been Signed on 04/21/2022 05:11 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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2022
Section Cited

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(h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) - (F)

This requirement is not met as evidence by:
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Based on record review, interview, and observation the assisted living medication room did not ensure resident's centrally stored medication records were maintained 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: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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
VISIT DATE: 04/21/2022
NARRATIVE
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LPA interviewed two out of two staff who stated that sometimes the assisted living section was not logging residents medications in the centrally stored medication record due to be being understaffed.

Administrator states the facility will be increasing to two MedTechs in the AM shift to lift the workload for the one NOC shift staff. During visit, staff corrected the issues in front of the LPA.

A deficiency was cited today per California Code of Regulation, Title 22. See LIC-809D.

A plan of correction was developed with the Administrator. This report was reviewed with Sara Post and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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