435202847-7-9-2024-26-AS-KHOS-D8JQBM-20240827120147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:29:55 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
06/17/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220617121040

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:	12:25 PM
MET WITH:	Val Baldugo		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility has insufficient staffing.

INVESTIGATION FINDINGS:

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

On 06/17/2022, the Department received a complaint with the allegation that the facility has insufficient staffing.

On 06/23/2022, the Department conducted an initial investigation visit.

LPA interviewed 4 staff and 2 residents. LPA toured the facility.

Continue on LIC9099-C. Page 1 of 2.

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 2

Control Number 26-AS-20220617121040

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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Facility has insufficient staffing:
On 06/23/2022, LPA interviewed 5 staff. Staff S1 stated the facility is actively hiring more staff. S1 stated there were 1 nurse, 5 caregivers, 1 Med Tech, a leader of Med Techs/caregivers group, 3 cooks, 3 servers, 3 house keepers and 1 laundry staff on duty. S1 stated the facility had a management team change recently which causes some staff left the jobs. S1 stated there are 9 applicants under the process of hiring and will be on board soon. S1 stated a new Executive Director will be on board next month.

LPA interviewed 3 staff. 2 out of 3 staff stated the facility does not have staffing issue. 1 out of 3 staff stated the facility could hire more staff.

LPA toured 3 resident rooms and interviewed 2 residents and one family member of resident. 2 out of 3 stated the facility's basic operation has no problem and the residents receive the cares they need. 1 out 3 stated the facility should hire more staff.

On 5/23/2024, LPA interviewed 7 staff. 6 out of 7 stated there are 8 caregivers, 2 Med Tech, 1 leader of Med Tech/caregivers group and 1 nurse on duty, and they all think the facility does not have insufficient staffing issue.

LPA interviewed 9 residents. 8 out of 9 residents stated the facility does not have insufficient staffing issue. 1 out of 9 residents stated the facility can hire more staff.

Based on the interviews with staff and residents and records reviewed, no evidence ti indicate the facility has insufficient staffing.

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 2 of 2.

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 2