435202623-11-7-2024-26-AS-ACON-DAZUZJ-20241114150136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:18:01 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
10/24/2024 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241024162149

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: 63	DATE:	11/07/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Chris Schuster, Baneer Amiri, Stephenie Brice		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident is being neglected due to bruisings.

INVESTIGATION FINDINGS:

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On 11/07/2024 Licensing Program Analyst (LPAs) Kiran Jain and Grace Donato conducted an unannounced complaint investigation visit and met with Executive Director, Chris Schuster. LPAs explained the purpose of the visit.

Regarding the allegations that the Resident is being neglected due to bruisings, the reporting Party (RP) mentioned that they received a call from a Stanford Hospital Social Worker regarding bruising. Client is a fall risk, has dementia and oriented to person only at baseline. Client had bruising on their right toe, and right cheek bone area that looked consistent with a fall. Client has daytime one-to-one care, but no overnight care. The facility is not sure how the fall occurred as it was unwitnessed. Client's family member reported to the hospital that client has history of falls and had no concerns about the skilled facility's care of client. Client was transported to the hospital the week prior to 10/17/24 for a fall that required stitches from a laceration on their left hip. Client has returned to the facility from Stanford Hospital, date unknown.

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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: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 3

Control Number 26-AS-20241024162149

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: 11/07/2024

NARRATIVE

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Based on the interview conducted with resident (R1)’s Family Member (FM1) on 10/29/2024, FM1 is aware of R1’s fall history and stated that R1 likes to do things on their own and doesn’t call for help. R1 was getting up and falling without assistance and people around due to medicine drowsiness. R1 had a cut on her backside and a bruise on her cheek. FM1 stated that this particular incident related to bruising was an unwitnessed fall. The facility is not sure how it happened and what caused the bruising. Most probably R1 hit the corner of the bed when they tried to move from the bed to the wheelchair on their own. Probably hit the chair or bed. R1 has Parkinson's dementia. R1 knows they can’t get up on their own. FM1 worked with R1’s doctor to change the medicine so that R1 is not always drowsy. No falls since the change of medicine. FM1 stated they hired a private companion for R1 and adding a private companion helped. FM1 is evaluating if R1 needs a skilled nursing home more than an Assisted Living facility. FM1 stated that the facility is doing a good job taking care of R1, giving medicines, showering, giving meals, and dressing. FM1 have been at the facility when they were working with R1. FM1 has no concerns about the facility, and they got a call every time a fall incident happened, and an EMT was called on all occasions.

Based on the interview conducted with staff (S1) on 10/30/2024, S1 stated that R1 moved into the facility about 2 months ago. R1 moved to Assisted Living from rehab with a dog. The facility evaluated and moved R1 from Assisted Living to memory care on the first day only. R1 was constantly tripping over the dog. The dog was handed over to R1’s FM1. S1 stated that R1 is confused, agitated, and suicidal at times, and has a high fall risk. R1 always tries to get out of bed and wheelchair on their own. R1 was in the hospital with bruising. The facility had a care plan around that. R1 is back in the facility from skilled nursing after the last surgery for a fall. The staff brings R1 to the common area of the memory care to do activities and manage and prevent falls/injuries. R1 is angry. R1 doesn’t want to be here. R1 is in her 90s. Bruising is due to the falls. All of R1’s falls are documented/reported on internal charting notes. Staff keep observing R1’s bruising and document its status. S1 stated that R1 has a personal companion from 12-8 PM. This changed her condition. R1 is more clear now. At nighttime, there is no personal companion. However, the facility’s care staff is there during the night shift. R1 has a pendant. R1 is using it. R1 is refusing medication at times. S1 stated that facility staff contacted and worked with R1’s responsible party, doctor, and skilled nursing home to address the injuries from fall incidents and help in managing the falls.

Based on the interview conducted with R1’s Personal Companion (PC1) on 11/05/2024, PC1 stated that the facility has been doing well in taking care of R1. R1 has been doing better. Caregivers are always attentive to R1. R1 tries to get out of bed knowing they can't walk and that is the reason they fall. R1 has been active, and the bruising is getting better. R1 has no fall incidents in the past 10 days.

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SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20241024162149

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: 11/07/2024

NARRATIVE

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Based on charting records review conducted on 11/05/2024, R1 has a high fall risk, is agitated on and off, confused at times, depressed, and verbally stated to kill themselves. On 10/06/2024, R1 was up half the night, agitated, and was throwing things. Medicine was given and was effective. The facility noticed a bump on R1’s right cheek. R1 stated that they tried to pick a fork up and bumped their cheek on the table. Ice pack and pain reliver was given. Family and MD were notified. Staff continued to monitor the bump, R1’s comfort level and continued with the care plan and medications. On 10/14/2024 around 6:20 AM, R1 was found on the floor in half sitting position. R1’s left thigh laceration was noted to be bleeding. 911 was called, the wound was treated, R1 was transferred to the hospital and RP was notified. R1 came back from the hospital on 10/14/2024 at 1:50 PM with a new medication order, had stitches on their laceration, and had 10 stitches on their left outer gluteal. R1 was stable but confused a lot. The facility continued with R1’s care plan, medications, and check on their comfort by monitoring R1. A private companion is with R1 from 12 PM to 8 PM. On 10/17/2024, the facility noted R1’s bleeding at the laceration site with a soiled dressing and sent R1 to ER. R1 came back from the hospital on 10/18/2024 with an updated medication list. No discomfort noted, old bruises on cheek, and forehead are still there. No new falls have been observed since 10/19/2024. On 10/21/2024, R1 was seen by Sutter Home Care, provided wound care, changed dressing, and no infection was noted. On 10/22/2204 R1 had lunch in the dining area. No new bruising was noted.

Based on hospital discharge records review conducted on 11/05/2024, R1 has poor safety awareness, is impulsive, has decreased attention/concentration, is disoriented to circumstances and time, and has short-term and long-term memory loss. Medications were updated. The functional assessment mentions that R1 needs assistance in bathing, oral hygiene, and other activities.

Based on interviews conducted with the staff, family member, personal companion, 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 Chris Schuster and a copy of this report was provided.

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END OF REPORT.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC9099 (FAS) - (06/04)

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