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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202623
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:43:09 PM

Document Has Been Signed on 12/05/2024 03:43 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: 67DATE:
12/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Stephanie BriceTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Marrufo conducted an unannounced Case Management visit and met with Stephanie Brice, Administrator.

LPA Marrufo obtained a copy of the facility California Residential Care Theft & Loss Policy and Procedure document. The documents states on page 1, “2. THEFT & LOSS – The Community shall document the loss or theft of personal property (in accordance with Section 2.A, below) with a then-current value of $25.00 or more within 72 hours of the Community’s discovery of such loss or theft.” The document states on page 2, “7. POSTING – This Policy shall be posted in a location easily visible to the residents of the Community.”
The facility submitted an LIC624 Unusual Incident/Injury Report to the Department on 05/26/2023. The report stated that on 05/21/2023, resident R1 reported that $400 was missing from R1’s apartment.

LPA Marrufo obtained a Progress Note for resident R1 dated 06/22/2023. The Progress Note stated that resident R1 reported to facility staff that a diamond ring belonging to R1 and R1’s spouse, R2, was missing.

During visit on 06/30/2023, LPA reviewed resident and facility records as part of a complaint investigation visit. LPA observed that there was no LIC9060 Theft and Loss Record form completed for the missing $400 and diamond ring that belonged to R1 and R2.

During visit on 07/10/2023, LPA interviewed Administrator Kathleen Olson, who stated that there is no Theft and Loss Policy posted in the facility. LPA did not observe a Theft and Loss Policy posted during visit.

Deficiencies were made as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Administrator Stephanie Brice and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 12/05/2024 03:43 PM - It Cannot Be Edited


Created By: David Marrufo On 12/05/2024 at 11:28 AM
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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2024
Section Cited
HSC
1569.153(a)

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1569.153 (a) Theft and loss program; standards, property inventories and surrender of personal effects; secured areas: A theft and loss program shall be implemented by the residential care facilities for the elderly within 90 days
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Licensee agrees to post the facility’s policy regarding theft and investigative procedures and provide photographic evidence to CCL by POC date.
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after January 1, 1989. The program shall include all of the following: (a) Establishment and posting of the facility's policy regarding theft and investigative procedures. This requirement was not met as evidenced by: Licensee did not ensure that the facility policy regarding theft and investigative procedures was posted at the facility, which poses a potential safety risk to residents in care.
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Deficiency Dismissed
Type B
12/12/2024
Section Cited
HSC1569.153(c)(1)-(5)

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1569.153 (c) (1)-(5) Theft and loss program; standards, property inventories and surrender of personal effects; secured areas: (c) Documentation of lost and stolen resident property with a value of twenty-five dollars ($ 25) or more
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Licensee agrees to conduct in-service training for staff on the requirement to ensure that a Theft and Loss Record is made when a resident’s belongings are lost or stolen. Once training is completed, Licensee agrees to submit copies of
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within 72 hours of the discovery of the loss or theft and, upon request, the documented theft and loss record for the past 12 months shall be made available to the State Department of Social Services, law enforcement agencies and to the office of the State Long-Term Care Ombudsman in response to a specific complaint. The documentation shall include, but not be limited to, the following: (1) A description of the article (2) Its estimated value. (3) The date and time the theft or loss was discovered. (4) If determinable, the date and time the loss or theft occurred. (5) The action taken. This requirement was not met as evidenced by: Licensee did not ensure that a Theft and Loss Record was made within 72 hours for the $400 and diamond ring belonging to R1 and R2 went missing, which poses a potential safety risk to residents in care.
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training records to CCL that include names of staff trained, dates of training, and names and qualifications of trainer(s).
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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