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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202623
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:47:08 PM

Document Has Been Signed on 11/15/2024 01:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 ALTOFACILITY NUMBER:
435202623
ADMINISTRATOR/
DIRECTOR:		FRANGIEH, CAROLINEFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO REALTELEPHONE:
(703) 273-7500
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY: 97CENSUS: 64DATE:
11/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Baneen Amiri and Stephenie BriceTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On November 15, 2024, Licensing Program Analyst (LPA) Kiran Jain conducted an unannounced case management visit. LPA met with Health Services Director (HSD), Baneen Amiri and Executive Director (ED), Stephenie Brice and explained the purpose of the visit.

During the investigation of complaint control number #26-AS-20241024162149, LPA Jain reviewed the facility's incident reports for Resident (R1) and found that the facility did not send any incident reports for R1 to Licensing in which R1 had fall incidents and or was sent to the hospital, from August 31, 2024 to October 17, 2024.

Based on the records review done for the facility's internal charting notes records for R1, the following incidents were documented:

  • R1 had fall episodes on 08/31/2024, 10/11/2024, 10/13/2024, and 10/14/2024.
  • The facility observed a bump on R1's right cheek on 10/06/2024.
  • R1 was sent to the hospital on 08/31/2024, 10/11/2024, 10/14/2024, and 10/17/2024.

Based on the interview conducted with staff HSD and ED, HSD stated they are not able to keep up and send UIR due to so many fall incidents. Everything related to the falls has been sent and communicated with the family and doctor for any changes from falls, cuts, and increased confusion from R1’s baseline. HSD stated they would send incident reports regarding falls or any other change of condition to the Licensing in the future.

Based on record reviewed and interview conducted, the facility did not submit Incident Reports to the Licensing when R1 had multiple fall incidents in the facility and or was sent to the hospital from August 31 to October 17 in 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

A deficiency was cited under the California Code of Regulations, Title 22. Failure to correct the deficiency by the due date may result in civil penalties. See LIC 809-D page for more information.

This report was reviewed with Baneen Amiri and Stephenie Brice, and a copy of this report along with appeal rights were provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2024 01:47 PM - It Cannot Be Edited


Created By: Kiran Jain On 11/15/2024 at 01:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/16/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident...

This requirement is not met as evidenced by:
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Licensee stated to submit a written plan of action understanding the regulation and will ensure a written report is submitted to the licensing agency within 7 days of the occurrence of the incident by the POC due date of 11/16/2024. The licensee agreed and understood.
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Based on record review and interview, the facility did not submit Incident Reports to the Licensing when R1 had multiple fall incidents in the facility and or was sent to the hospital from August 31 to October 17 in 2024 which poses/posed a potential 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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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