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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202623
Report Date: 10/25/2023
Date Signed: 10/25/2023 01:07:29 PM


Document Has Been Signed on 10/25/2023 01:07 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:FRANGIEH, CAROLINEFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO REALTELEPHONE:
(703) 273-7500
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:97CENSUS: 73DATE:
10/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Andrew PenceTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Andrew Pence. The purpose of the visit was to address additional reports that were brought up as part of a previous complaint investigation.

On 10/19/2023, LPA Marrufo interviewed resident R1's Responsible Party, who stated to have observed R1 have a fall in the shower while being assisted by a staff. R1's Responsible Party stated the fall occurred sometime around 3-5 months ago. R1's Responsible Party stated R1 was holding on to the grab bar in the shower when R1 began to lose balance and slid down to the shower floor. R1's Responsible Party stated to have asked the staff if the staff was going to report the fall, and the staff stated stated he/she would report the fall. R1's Responsible Party did not know the name of the staff who assisted R1 in the shower and witnessed R1's fall. R1's Responsible Party also reported to have spoken to another staff who was a medication manager on the memory care floor of the facility and reported the fall to the medication manager. R1's Responsible Party could not recall the name of the medication manager to whom R1's Responsible Party reported R1's fall.

During visit, LPA Marrufo interviewed staff S1-S5 and resident R1. Staff S1-S5 stated to have not observed any incidents in which R1 fell in the shower. S1-S5 stated that a resident falling in the shower, including if the resident slides to the floor after losing balance, should be reported.

Review of resident records indicate that there is no record of the witnessed fall that R1 had in the shower.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Andrew Pence and a copy of the report and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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