435202621-3-28-2024-26-AS-RMAO-D5WL9N-20240604083347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202621
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:06:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
02/16/2022 and conducted by Evaluator Maria Partoza

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220216155931

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202621
ADMINISTRATOR:	MICHAEL FOUNTAIN		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE RD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	0	CENSUS: 0	DATE:	03/28/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Karina Nevarez		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff struck client in the face

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver complaint finding and met with current executive director (ED) Karina Nevarez.

On 2/16/2022, the Department received a complaint that a staff struck a client in the face.

On 2/25/2022, the Department conducted an initial investigation of the above allegations. During the initial investigation LPA requested for the following documents: Resident Care Notes, Physicians Report (LIC 602 A), Appraisal Needs & Services Plan, Personal Rights (SOC 341A) and the police report.. LPA interviewed 2 staff (S1 to S2) and 1 resident (R1).

See LIC 9099-C
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2024

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 26-AS-20220216155931

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN JOSE	FACILITY NUMBER: 435202621
	VISIT DATE: 03/28/2024

NARRATIVE

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Based on interview and documentation dated 2/14/2022 R1 had a change in condition. R1 reacts aggressively when touched during administration of activity of daily living (ADL).

On 2/14/2022 at approximately 1657 hours, the law enforcement agency responded and investigated the incident of possible elder abuse by a staff. Based on the interview and documentation. Law enforcement noted that R1 has neurocognitive impairment. Based on the law enforcement report R1 claims staff did not hit him/her on the face.

During interview S1 stated that R1 became aggressive, and to prevent R1 from falling S1 held R1s hands because the floor was slippery and wet.

Based on interviews conducted, observations, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations is UNSUBSTANTIATED.

No deficiencies were cited during today's vist and an exit interview was conducted with current executive director (ED) Karina Nevarez.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC9099 (FAS) - (06/04)

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