435202623-9-6-2024-26-AS-KHOS-D96JYG-20240916072754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:52:29 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
12/11/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231211152500

FACILITY NAME:	IVY PARK AT PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	FRANGIEH, CAROLINE		FACILITY TYPE:	740
ADDRESS:	2701 EL CAMINO REAL		TELEPHONE:	(703) 273-7500
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	97	CENSUS: 69	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Baneen Amiri		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff physically manhandled the resident that caused bruising on the left forearm.
Staff hit resident while in care.

INVESTIGATION FINDINGS:

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On 9/6/24 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit and met with Health Services Director Baneen Amiri. LPA explained the purpose of the visit.

Regarding the allegations of staff physically manhandled the resident that caused bruising on the left forearm and staff hit resident while in care, Reporting Party (RP) mentioned that resident R1 stated that he/she was hit by the staff, and they were roughly handling him/her while getting ready for the day. Per RP, R1 stated staff squeezed his/her left arm and R1 hit the caregiver because of the pain he/she was experiencing and in turn the caregiver hit R1 back on the left forearm. Per RP the squeezing and hitting caused R1 to bruise on the left forearm.

con't ....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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 4

Control Number 26-AS-20231211152500

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: 09/06/2024

NARRATIVE

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Based on records review, a police report was obtained by LPA, Staff member (S1) stated that When S1 and S2 went to help R1 get dressed for breakfast, R1 told them he/she didn't want to get up because he/she was sick. S1 then reported to the medical technician. When S1 and S2 went back to assist R1 they attempted to remove the blanket to help R1 get out of bed. When they removed the blanket, S1 observed a bottle of wine on R1's lap. When S1 attempted to grab the wine bottle from R1s lap, R1 became combative and pulled S1s hair. As R1 pulled S1's hair, R1 continuously yelled at them to get out of the room.

For R1s statement, on 11-26-23, R1 alleged that caregiver S1 and S2 entered the room and grabbed R1s left forearm and left leg to help R1 get dressed for breakfast. R1 stated he/she did not want to go and told them to leave her alone, but they didn't. When R1 asked S1 to take her to the bathroom, S1 told her “No.'' S1 stormed out of the room and slammed the door on the way out. When R1 was asked if S1 ever struck him/her, R1 stated yes. R1 stated that S1 did not actually strike him/her but was rough and aggressive when trying to get him/her dressed for breakfast. R1 admitted that he/she struck S1 in the chest area when R1 tried dressing him/her because she was squeezing his/her arm tightly.

The Administrator (ADM) during this time stated that after these allegations were made, ADM had a nurse at the facility conduct a head-to-toe skin check on R1 the following day (11-27-23). ADM advised that during this physical check, Health Services Director (HSD) did not observe any visible bruising on R1. ADM also stated that RP was not present but stated that one of the caregivers struck R1 in the back and arm, which caused bruising on R1s body. Also in the police report, it was mentioned that from what the Police Officer (PO) observed, R1 did not have any visible injuries when the arm was inspected. The photographs RP took, and it did not appear that R1 was bruised. However, there was slight redness likely to be because of age/sensitive skin.

LPA Marrufo was also able to interview staff members. During the interview, S2 was asked if he/she witnessed R1 being hurt by S2 and stated that “No, I didn’t.” S2 did not see personally that S1 hit R1 because S2s back was turned. S2 tried calming R1 down but that is when R1 scratched S2s wrist. R1 was very anxious and aggressive. S2 also did not observed any injuries on R1s forearm.

Based on interviews & records review, the department has determined that although the allegations 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.

Report is reviewed and copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
12/11/2023 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 26-AS-20231211152500

FACILITY NAME:	IVY PARK AT PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	FRANGIEH, CAROLINE		FACILITY TYPE:	740
ADDRESS:	2701 EL CAMINO REAL		TELEPHONE:	(703) 273-7500
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	97	CENSUS: 69	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Baneen Amiri		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff neglected the resident by not taking her to get breakfast.

INVESTIGATION FINDINGS:

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On 9/6/24 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit and met with Health Services Director Baneen Amiri. LPA explained the purpose of the visit.

Regarding the allegation of staff neglected the resident by not taking R1 to get breakfast, RP stated staff left R1 in the room causing R1 to miss breakfast.

LPA Marrufo interviewed RP and it was stated that staff did get R1 dressed in R1’s wheelchair and left R1 there. R1 normally gets into breakfast by 8:00 AM, and RP got there around 8:45AM and took R1 to breakfast. At some point a caregiver from a different floor came by. They did not say anything about why they hadn’t taken R1 to breakfast. They just said they were short staffed, and they were the only ones working that floor and another floor.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20231211152500

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: 09/06/2024

NARRATIVE

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However, due to the incidents that R1 was refusing care and assistance from the staff, they were only able to dress R1. Also based on the police report, R1 continuously yelled at the staff to get out. While there may be staffing issues during this day, the Facility was already allocating staff to assist other residents.

LPA Marrufo was able to interview another staff member (S3), and it was mentioned that the family member (F1) came the moment S3 was with R1. F1 asked S3 what happened and S3 said “I didn’t know.” F1 told S3 that he/she would lower R1 down to the dining room for breakfast. It was in the morning. S3 normally lower the resident’s downstairs to the dining room for breakfast. F1 said don’t worry, and that F1 will take R1 to breakfast.

Based on interviews and observations, the department has determined that that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4