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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 03/27/2025
Date Signed: 03/27/2025 03:06:36 PM

Substantiated


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
02/19/2025 and conducted by Evaluator Kiran Jain
COMPLAINT CONTROL NUMBER: 26-AS-20250219092649
FACILITY NAME:IVY PARK AT PALO ALTOFACILITY NUMBER:
435202623
ADMINISTRATOR:STEPHANIE BRICEFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO REALTELEPHONE:
(703) 273-7500
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:97CENSUS: 66DATE:
03/27/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Stephanie BriceTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff administered the incorrect medication resulting in a resident's hospitalization
INVESTIGATION FINDINGS:
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On March 27, 2025, at 2:20 PM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Executive Director (ED), Stephanie Brice. The LPA disclosed the purpose of the inspection. The ED informed the LPA that there were (66) residents in care.

Regarding the allegation “Staff administered the incorrect medication resulting in a resident's hospitalization”, the Reporting Party (RP) stated “R1 returned to the facility from skilled nursing, and their updated medication list was not sent to the pharmacy causing the staff to administer the wrong medication to the resident. RP reported that the facility administered a medication to the resident that R1 was no longer taking causing severe low blood glucose. RP reported that on 02/17/25, the resident had to be transported to the hospital and was admitted to the ICU.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
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 5
Control Number 26-AS-20250219092649
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 PALO ALTO
FACILITY NUMBER: 435202623
VISIT DATE: 03/27/2025
NARRATIVE
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RP reported that when the staff were asked about the medication list that was being used, the staff told the RP that the list was faxed to their medication pharmacy however there were no records of the fax being sent. RP reported that the resident is no longer in ICU but is still hospitalized”.

LPA interviewed five (5) staff members (ED, HSD, S1, S2, and S3).

ED stated the staff should have caught the medication by going over the discharge paperwork. R1 has been at a skilled nursing facility since November 2024. The staff went to assess R1 on 02/12/2025 and saw the updated LIC602 and updated medication list. The actual papers/forms were emailed on 02/12/2025. The resident came back to the facility on 02/14/2025 around 10 AM. ED stated that the R1’s primary care physician (PCP) was notified that the facility gave Glipizide medicine which was not on their discharge paperwork.

S1 stated that on 02/14/2025 around 5 PM, they administered Glipizide to R1. The medication was still listed on the QMAR, and there was no discontinuation on it.

S2 stated that they were working on 02/14/2025 when R1 returned to the facility from the skilled nursing facility. S2 stated that R1 brought discharge papers and a medication bag containing medications from the skilled nursing facility. S2 gave the discharge papers to HSD and centrally logged the medications. S2 stated that, to their knowledge, Glipizide was not in the bag. They also stated that they did not know why Glipizide was still listed on the QMAR.

S3 stated that they administered Glipizide to R1 on 02/14/2025 between 7:00 and 7:30 PM. Since Glipizide was listed on the QMAR, they believed it was appropriate to administer it. S3 stated that on 02/17/2025 at 7:00 AM, they went to check on R1 and found R1 sleeping but unconscious. S3 measured R1’s blood sugar at 46 and called 911. S3 did not administer Glipizide or any other medications on the morning of 02/17/2025, as R1 was unconscious. S3 stated that R1’s discharge papers from the skilled nursing facility should have been reviewed to update the QMAR.

HSD stated that they went to the skilled nursing facility to assess R1, and Glipizide was not listed on the paperwork. HSD further stated that the skilled nursing facility did not provide the correct medication list on the discharge papers. The medication list was not current, and they were looking at it as incomplete. HSD stated that Glipizide was not listed in the medication list received when R1 returned to the facility. This medication list was identical to the one received during the assessment visit.

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20250219092649
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 PALO ALTO
FACILITY NUMBER: 435202623
VISIT DATE: 03/27/2025
NARRATIVE
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LPA interviewed two (2) family members (FM1 and FM2).

FM2 stated from early December through February 14, R1 has been at the hospital or skilled nursing facility. The skilled nursing facility sent R1’s medication list and discharge notice a day prior via email to the nurses at Ivy Park. However, Ivy Park failed to update the medication list even though they had it. Ivy Park used the medication list from November 2024 and in 3 months R1’s medications had changed greatly. Ivy Park said there was no update. FM2 stated they asked them “Did you look at the discharge papers” and they said yes. But they didn’t till after FM2 asked them to. FM2 stated that Glipizide medicine was prescribed to R1 from November 2024 medication list but was discontinued when R1 returned from the skilled nursing facility on 02/14/2025.

FM1 stated that they visited R1 two to three times a week and used to care for R1 themselves prior to R1’s move to Ivy Park. FM1 stated their concern that the nursing director had recently left, and the new director was not involved. As a result, they felt that many of the services R1 needed were lacking.

LPA reviewed R1’s LIC602 Physician’s Report, dated 02/12/2025, which was signed by the physician at the skilled nursing facility.

LPA reviewed R1’s discharge summary report from the skilled nursing facility, dated 02/12/2025, which included the physician’s name (MJ) and the pharmacy’s name (OMN). Glipizide was not listed under the pharmacy order summary.

LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR). The Glipizide medication was not listed among the medications entered for the skilled nursing facility’s prescribing physician (MJ) and the pharmacy (OMN).

LPA reviewed the fax report that was sent on 02/17/2025 by the facility to R1’s physician. The report stated that R1 had received ‘Glipizide 5 mg’ at 8 PM on 02/14/2025, at 8 AM and 8 PM on 02/15/2025, and at 8 AM on 02/16/2025. R1 had previously been on ‘Glipizide’ but this medication was not on his discharge paperwork from skilled nursing facility (SNF) on 2/14/2025. R1 was sent to the ER due to low blood sugar.

LPA reviewed R1’s QMAR records. According to the first QMAR, printed on 02/18/2025, the Glipizide medication was not marked as ‘Discontinued’ and was recorded as administered on 02/14/2025, 02/15/2025, and 02/16/2025. According to the second QMAR, printed on 02/24/2025, Glipizide was marked as ‘Discontinued’ with a stop date of 02/17/2025 at 2:00 PM.

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20250219092649
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 PALO ALTO
FACILITY NUMBER: 435202623
VISIT DATE: 03/27/2025
NARRATIVE
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Based on LPA’s observations and interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

A deficiency in accordance with the California Code of Regulations, (Title 22, Division 6 & Chapter 8), was cited on the attached LIC9099-D.

An exit interview was conducted, and the Plan of Correction was reviewed and developed with the Executive Director. A copy of this report and appeal rights were discussed and left with the Executive Director, Stephanie Brice, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20250219092649
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 PALO ALTO
FACILITY NUMBER: 435202623
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2025
Section Cited
CCR
87465(a)(5)(A)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical… (5) … Assistance with self-administered medications… (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.
This requirement was not met as evidenced by:
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The Executive Director will develop a plan to ensure correct medications prescribed by physicians are given to the residents. The Executive Director will provide a copy of the plan to CCLD by 03/28/2025.
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Based on observations, interviews, and records review, the facility staff did not ensure R1 was given the correct prescribed medication authorized by R1’s skilled nursing facility’s physician upon R1’s return from the skilled nursing facility, which posed an immediate health, safety, or 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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5