435202623-12-5-2024-26-AS-KHOS-DBTKTF-20241210071105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:13:38 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
07/08/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240708100511

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: 67	DATE:	12/05/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Stephanie Brice		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not ensure residents care plan is properly followed
Staff did not observe changes in residents health condition in a timely manner
Staff are not assisting resident with administration of medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Stephanie Brice, Administrator.

On 07/08/2024, the Department received a complaint with the above allegations. On 07/16/2024, LPA Marrufo conducted an initial complaint investigation visit.

Resident R1’s Service Plan states R1 requires medication assistance and requires monitoring of weight gain or loss once per week.

During interview on 07/16/2024, resident R1 stated that R1 uses a scale to check R1’s weight and records R1’s weight every day in a handwritten log. LPA observed R1’s handwritten daily weight log. R1 stated that R1’s weight scale has not been broken. See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20240708100511

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: 12/05/2024

NARRATIVE

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During interview on 07/16/2024, staff S1 stated R1 weighs himself/herself daily and keeps a daily weight log. S1 stated staff check R1’s daily weight log each morning.

During interview on 12/05/2024, S1 stated that staff would review R1’s daily weight log, but staff did not record R1’s daily weight in any facility records.

During interview on 12/05/2024, S2 stated to have observed R1 experience worsening breathing. S2 stated to have reported S2’s observations about R1’s worsening breathing to S1 and S3, who was the Wellness Nurse at the time. S2 stated to have notified R1’s physician via fax about R1’s worsening breathing.

R1’s Progress Notes state that on 01/17/2024, R1 was transferred to the hospital for tremors, difficulty swallowing, and shortness of breath. The Progress Notes state that R1’s doctor and family member were notified.

R1’s Progress Notes state that on 06/18/2024, facility staff called 911 to have R1 transported to the hospital for shortness of breath.

LPA Marrufo obtained a copy of R1’s Medication Administration Record (MAR) from June and July 2024. The MAR indicates that all centrally stored medications were administered to R1 each day that R1 was at the facility.

LPA obtained a copy of a faxed Memorandum from R1’s physician. The Memorandum is dated 07/03/2024. The Memorandum states that staff should assist R1 with administering Medication M1 every day between 8:00 AM to 9:00 AM. The Memorandum also states if R1 weighs more than 183 pounds, staff should assist R1 in administering another dosage of M1.

LPA Marrufo obtained a copy of R1’s Administration History of Medication M1, which states R1 received a medication on time every day from 07/06/2024 to 07/15/2024.

Page 2 of 3.

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240708100511

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: 12/05/2024

NARRATIVE

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During interview on 07/16/2024, R1 stated that facility staff provided R1 with only one dosage of M1 per day, but the staff were supposed to provide R1 with two dosages of M1 per day.

During interview on 07/16/2024, S1 stated that staff check R1’s weight log each day to determine if R1 will need a second dosage of M1 at 2 PM.

Based on information from interviews conducted with staff, 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 were cited under California Code of Regulations Title 22

This report was reviewed with Stephanie Brice, Administrator, and a copy of this report was provided.

Page 3 of 3.

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3