435202847-11-15-2024-26-AS-KHOS-DBCQQL-20241125112232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 11/15/2024
Date Signed: 11/15/2024 04:50:03 PM

Unfounded

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
03/06/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240306095915

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202847
ADMINISTRATOR:	NEVAREZ, KARINA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE ROAD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 120	DATE:	11/15/2024
		UNANNOUNCED	TIME BEGAN:	02:39 PM
MET WITH:	Val Baldugo Macasieb		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

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Staff did not administer resident's medication as prescribed.
Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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

On 3/6/2024, the Department received a complaint with the allegations that staff did not administer resident's medication as prescribed and staff did not seek medical attention in a timely manner.

On 3/12/2024, the Department conducted an initial investigation visit.

LPA interviewed Executive Director (ED) and Resident Service Director (RSD).

LPA requested copies of R1's resident records, including R1's Physician's Report, R1's Needs and Services Plan, R1's PRN Authorization Letter, R1's MARs, and R1's Progress Notes.
Continue on LIC9099-C. page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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-20240306095915

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 SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 11/15/2024

NARRATIVE

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Staff did not administer resident's medication as prescribed:

The allegation is that the facility did not administer resident R1's PRN medication to R1.

On 3/12/2024, LPA interviewed Executive Director (ED) Karina Nevarez. ED stated resident R1 is a resident in memory Care Unit, and is under hospice care. ED stated the medication that did not administer to R1 is PRN medication meaning to administer to resident as needed. ED stated the symptoms R1 had were related to the Hospice diagnosis. ED stated the staff called R1's hospice agency for advice. ED stated R1's hospice agency had given the approval for the R1's family member (FM) to carry R1's PRN medication and to administer the medication as need.

LPA interviewed Resident Service Director (RSD). RSD stated resident R1 is under hospice care. RSD stated the protocol for resident who is on hospice care and having symptoms related to the hospice diagnosis is to call hospice nurse for advice. RSD stated on 2/17/2024, R1 had the symptom of chest pain which is the symptoms related to R1's hospice diagnosis. RSD stated the facility staff contacted hospice nurse and Hospice nurse arrived at the facility at approximately 6:00PM on 2/17/2024.

Based on the review of R1's physician report, R1 is on hospice care. Based on the review of R1's Individualized Service Plan, R1's has Special Medical Needs that R1 requires service from hospice staff.

Based on the interview and records reviewed, R1 was under hospice care. R1 had the symptom same as R1's hospice diagnosis. The facility staff are not allowed to administer R1's PRN medication to R1. The facility staff need to call hospice care nurse for advice.

Staff did not seek medical attention in a timely manner:

The allegation is that resident R1's family member (FM) called a facility staff that R1 needed PRN medication when R1 had pain, but it took around 37 minutes to get the PRN medication.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240306095915

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 SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 11/15/2024

NARRATIVE

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On 3/12/2024, LPA interviewed Executive Director (ED) Karina Nevarez. ED stated resident R1 was under hospice care. ED stated during the incident, the symptoms R1 had were related to R1's Hospice diagnosis. ED stated the staff need to call R1's hospice agency for advice first. ED stated the staff received FM's call, actually was busy at another building and was having an emergency situation which needed to finish first. ED stated S1 went to R1 after the facility received R1's hospice care nurse's advice and after S1 finished the situation of emergency.

ED stated R1's hospice agency had given the approval for the R1's family member (FM) to carry R1's PRN medication and to administer the medication as need.

LPA interviewed Resident Service Director (RSD). RSD stated resident R1 is under hospice care and R1's symptom was same as R1's hospice diagnosis. RSD stated by protocol, the facility should contact R1's hospice care nurse for advice. RSD provided the text messages log with R1's family member (FM), Med Techs, and R1's hospice care nurse. RSD denied the facility staff neglect. RSD stated the facility staff were processing R1's situation during the incident.

Based on the review of R1's physician report, R1 is on hospice care. Based on the review of R1's individualized Service Plan, R1's has Special Medical Needs that R1 requires service from hospice staff.

Based on the review of RSD text messages logs with FM, facility Med Techs, and R1's hospice care nurse. The facility staff were seeking medication attention for R1.

The Department has investigated the above allegation. Based on the investigation, document reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with BOD. This report was provided to review and for signature. A copy of this report was provided to BOD.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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