435202623-10-18-2023-26-AS-KHOS-DAAMD6-20241022093038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:39:45 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
10/12/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231012133153

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: 73	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Andrew Pence		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff drink alcohol while working at the facility
Staff did not provide adequate mobility assistance to resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Andrew Pence.

During visit, LPA Marrufo toured the garage storage rooms and areas, employee lounge room, and facility kitchen. LPA Marrufo did not observe any alcoholic drink in those areas except for bottles and boxes of alcohol in the facility pantry. LPA Marrufo interviewed staff S1-S11 and residents R1-R6.

Staff S1 stated during interview that the facility serves alcohol to residents upon request and if the resident is able to drink alcohol. S1 stated the pantry is locked once meals are done being served.

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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-20231012133153

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: 10/18/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff S2-S11 and Residents R2-R6 stated during interview to have never observed alcohol in the facility besides in the kitchen area, to have never observed a staff consume alcohol at the facility, and to have never observed a staff appear to be under the influence of alcohol at the facility.

LPA Marrufo interviewed resident R1 who stated to have never had a resident drop R1 during a transfer. LPA Marrufo obtained a copy of R1's Appraisal/Needs and Services Plan, which states R1 needs transfer assistance from 1 staff.

Based on information from interviews conducted with staff and residents, 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 are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Andrew Pence and a copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2