435202847-7-9-2024-26-AS-KHOS-D8JQAJ-20240827120002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:28:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/10/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220610142646

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202847
ADMINISTRATOR:	POST, SARA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE ROAD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 124	DATE:	07/09/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Val Baldugo		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff are not answering resident call buttons timely due to insufficient staffing.
Residents are not receiving at least 3 meals a day.
Residents are not receiving meals timely.
Thermostat in resident's room is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Business Office Director (BOD) Val Baldugo.

On 06/10/2022, the Department received a complaint with the above allegations.

On 06/17/2022, the Department conducted an initial investigation visit.

LPA interviewed 2 staff and 3 residents.

LPA requested the rosters of residents and staff, call button logs, and work order log.

Continue on LIC9099-C. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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 4

Control Number 26-AS-20220610142646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/09/2024

NARRATIVE

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Staff are not answering resident call buttons timely due to insufficient staffing:
On 06/17/2022, LPA interviewed 2 staff. Both stated the facility was actively hiring staff. Both stated the facility just had the management team change. 1 out of 2 staff stated the facility's basic operation has no problem, because staff were working overtime to meet residents' needs. 1 out of 2 staff stated the facility staff respond to the call buttons around 10 minutes.

LPA interviewed 3 residents. 2 out of 3 stated it takes 10 to 20 minutes for staff to come to help when they pressed the call button for help. 1 out of 3 stated he/she had two times experiences that the staff's response time were longer than one hour when he/she pressed the call button for help, but other than that the staff's response time were within reasonable time.

LPA requested the facility call button logs, the facility was unable to provide for that time period.

On 05/23/2024, LPA interviewed 9 residents. 2 out 9 residents stated they have call button but they never used the call buttons. 7 out 9 residents stated the facility staff respond to the call buttons between 1 to 15 minutes.

Based on the interviews, there is no evidence to indicate the facility staff are not answering resident call buttons timely due to insufficient staffing.

Residents are not receiving at least 3 meals a day:
Residents are not receiving meals timely:
On 06/17/2022, LPA interviewed 2 staff. Both stated the facility dinning room opens from 7:00AM to 7:00PM every day to provide breakfast, lunch, dinner and snack. Both stated the facility provides room service for meals and the caregivers delivers the meals to resident rooms.

LPA toured 6 resident rooms with staff and interviewed residents. 3 out of 6 stated they go to the dining room for breakfast, lunch, and dinner, they did not have any complaint for the meal service. 2 out 6 just finished the lunch, and just wanted to take a nap and refused to get interview. 1 out of 6 resident was unable to talk, staff stated he/she already finished lunch.

Continue on LIC9099-C. Page 2 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20220610142646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/09/2024

NARRATIVE

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On 5/23/2024, LPA interviewed 9 residents. 3 out 9 residents stated they go to the dining room for breakfasts, lunches and dinners during the meal time. 5 out 9 stated they have breakfasts, lunches and dinners delivered to their room during the meal time. 1 out 9 stated he/she go to the dining room for breakfasts and lunches during the meal time, and the dinners were delivered to his/her room during the dinner time.

Based on the interviews, no evidence to indicate that residents did not receive 3 meals a day and no evidence to indicate residents are not receiving meals during the meal time.

Thermostat in resident's room is in disrepair:

On 06/17/2022, LPA interviewed 2 staff. Both stated the facility air condition was not working fine several days ago, but it was fixed.

LPA interviewed resident R1. R1 stated his/her room air condition was not working several days ago, but it was fixed. LPA requested the work orders for the air condition, the facility was unable to provide.

On 5/23/2024, LPA interviewed staff S1. S1 stated some residents sometimes maladjusted the thermostat accidentally and thought the air condition was not working. S1 stated if residents found maintenance staff around, then maintenance staff can fix it immediately. S1 stated if the residents asked caregivers to file a work order, and it usually will take one day to fix. S1 stated it will take longer if it needs to replace the parts depending on how soon the parts are available. S1 stated it usually takes around 3 days if needs to replace the parts. S1 stated from year 2022, the facility has upgraded the thermostats/air conditions and the system should be fine now. S1 stated the facility provides fan to the resident if the resident's room thermostat/air condition does not work.

LPA interviewed 9 residents. 9 out of 9 residents stated air conditions are working fine. 1 out of 9 residents stated he/she heard one resident's air condition was not working but was fixed within 3 days.

Continue on LIC9099-C. Page 3 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20220610142646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/09/2024

NARRATIVE

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Based on the interviews, most of the residents' room conditions/thermostats are working fine. Resident R1's thermostat/air condition was not working but was fixed within reasonable time period. One resident stated he/she heard one resident's air condition/thermostat was fixed within three days. The facility provides fan to resident if the resident's room air condition does not work during the repair time period.

Based on investigation, observations, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s compliant investigation visit. This report was provided to BOD for signature. A copy of the report was provided to BOD.

Page 4 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4