435202623-11-1-2024-26-AS-ACON-DAZUYZ-20241114150043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 11/01/2024
Date Signed: 11/01/2024 02:37:09 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
10/04/2024 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241004120232

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: 64	DATE:	11/01/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Baneen Amiri, Health Services Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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1. The facility did not assist in providing care with activities of daily living.
2. The facility did not consistently observe changes and address resident's physical, mental, emotional, or social functioning and did not provide appropriate assistance in response to these changes.
3. The facility did not provide adequate supervision or ensure proper assistance with the administration of medication.

INVESTIGATION FINDINGS:

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On 11/01/2024, Licensing Program Analysts (LPAs) Kiran Jain and 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 that the facility did not assist in providing care with activities of daily living, The facility did not consistently observe changes and address resident's physical, mental, emotional, or social functioning and did not provide appropriate assistance in response to these changes, and the facility did not provide adequate supervision or ensure proper assistance with the administration of medication, the reporting Party (RP) mentioned that Client (R1) has not showered in an unknown amount of time and the home is in disarray. The client has schizoaffective disorder and has not taken her medication in several months. RP attempted to contact the Client and she is very incoherent. RP attempted to evaluate Client for a psychiatric hold, but the Client did not want to speak with the RP.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

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-20241004120232

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: 11/01/2024

NARRATIVE

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Based on the interviews and records review, when facility staff went to check on R1 in their room, R1 slammed the door at staff, called names, and stated they were there to be independent and wished to be left alone. Staff said to let them know if R1 needs anything. R1 was seen in multiple rooms and locked themselves in the hallway bathroom. S3 attempted to speak to R1 and encouraged them to come out of the bathroom. Staff called 911 to seek help and quickly cleaned R1’s room. R1 continued to order meals delivered to their room for months and didn’t want to come down for meals or attend activities. Per R1, they are not a social person and prefer to stay at their pace.

R1 continued to refuse to take certain medications stating I have the right to refuse my medication. S3 tried to explain the side effect of refusing their medication but R1 refused to cooperate. Staff continued to document refused non-administered medications. S3 received a phone call from R1’s doctor to verbally OK to discontinue medication as R1 has the right to refuse. R1 was noted several times to be self-talking and knocking back at the door upon knocking. The facility continued to document, assist, and monitor R1’s changes and continued with the care plan. R1 was observed not to be sleeping well. Stay up the whole night crying, talking, and sometimes screaming. Neighboring residents complained about this behavior.

Based on the interviews and records view, S3 and S4 contacted R1’s case worker, VA advocate, PCP, and psychiatrist, the Mobile crisis unit, and the Police department. A police report was obtained by LPA. According to the police report, R1 made it clear that they did not want any service from the police department and slammed the door closed.

Based on information from interviews conducted with the staff and records reviewed, the department has determined that 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 were cited under the California Code of Regulations Title 22.

This report was reviewed with Baneen Amiri and a copy of this report was provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC9099 (FAS) - (06/04)

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