435202621-3-3-2022-26-AS-RMAO-D5WLAF-20240604083504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202621
Report Date: 03/03/2022
Date Signed: 03/03/2022 05:27:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220228150847

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202621
ADMINISTRATOR:	SARA POST		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE RD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 99	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	03:26 PM
MET WITH:	Sara Post		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Facility staff neglect resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation and met with Administrator Sara Post.

During visit, LPA Marrufo interviewed Administrator Sara Post and resident R1. LPA Marrufo obtained copies of the following documents for R1: Admission Agreement, Physician's Report dated 01/24/2022, Physician's Report dated 03/02/2022, Mini-Mental State Examinations (MMSE) dated 01/26/2022 and 02/25/2022, Facility Fax Report to R1's Primary Care Physician dated 02/24/2022, Resident Information Form, LIC624 Incident Report dated 03/01/2022, Individualized Service Plans dated 01/29/2022 and 03/01/2022, and Written Statement from Administrator Sara Post.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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 26-AS-20220228150847

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/03/2022

NARRATIVE

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Based on information from interviews conducted with resident and staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

Administrator Sara Post provided records of instances that the facility contacted R1's primary care physician and family when R1 experienced health issues and showed signs of cognitive and physical deterioration.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Administrator Sara Post and a copy of the report was provided.

Page 2 of 2.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2