435202847-6-14-2024-26-AS-MMOR-D692EL-20240614172003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202847
Report Date: 06/14/2024
Date Signed: 06/14/2024 05:20:23 PM

Document Has Been Signed on 06/14/2024 05:20 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 SAN JOSE		FACILITY NUMBER:	435202847
ADMINISTRATOR/ DIRECTOR:	NEVAREZ, KARINA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE ROAD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY: 140	TOTAL ENROLLED CHILDREN: 0	CENSUS: 127	DATE:	06/14/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Health Services Director John Doyle		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards to a phone call the Department received regarding R1 on June 14, 2024. LPA met with Health Services Director (HSD) John Doyle and explained the purpose of the visit. On June 14, 2024, the Department received a phone call from facility Administrator (ADM) Karina Nevarez who stated resident R1 was discovered missing on June 13, 2024 around 9:30pm. ADM stated that R1 was admitted to the facility on March 2024. ADM stated R1's secondary diagnosis is early onset of dementia. ADM stated that the resident likes to sit by the front but is always redirected back. ADM stated R1 resides in the assisted living section of the facility. ADM stated when staff were asked, no one saw R1 leave the facility and have knowledge which door was used by R1 to leave the facility. ADM stated that the family has been notified. ADM stated that SJPD with some facility staff were actively searching for the resident since yesterday and SJPD issued a SILVER ALERT (missing person). The Department received a follow up call from the facility ADM, stating the resident was found was in the hospital since the night before, at 12:10am. ADM stated R1 used the front door and walked to the shopping center near the facility. ADM stated the store clerk contacted 911, when R1 was unable to answer questions about where he/she lived and his/her name. ADM stated R1 stayed in the hospital overnight. ADM stated R1 was going to be transferred to memory care, but they do not have any availability. On June 14, 2024, LPA interviewed HSD. HSD stated the facility has 11 residents with dementia living in the assisted living section of the facility. HSD stated when R1 first moved in he/she would wander to the front or wander up and down the halls. HSD stated once R1 got new friends and joined activities, the wandering went down. Page 1 Out of 2.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/14/2024

NARRATIVE

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Based on a review of R1's physicians report dated August 28, 2023, R1 has dementia and cannot leave the facility unassisted.

A review of R1's Preplacement Appraisal states R1 has dementia. Under "needs special observation/night supervision (due to confusion, forgetfulness, wandering)", the preplacement appraisal has a question mark between the unchecked yes and no box.

Based on a review of R1's progress notes; R1 was noted to pace the floors on May 15, 2024. R1's Progress notes also states R1 was "wandering the halls" on May 16, 17, & 18.

A review of R1's Needs and services plan, dated April 1, 2024, under elopement risk status, the form states R1's elopement risk will be evaluated.

A review of R1's Elopement Risk Assessment, dated March 28, 2024 states R1 is not able to leave the facility unassisted.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility overnight.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Health Services Director John Doyle and a copy of the report was provided. Appeal Rights was provided.

END OF REPORT

Page 2 Out of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/14/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs ... by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by;
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 06/15/2024
	Plan of Correction
1 2 3 4	ADM stated she will conduct training for her staff regarding wandering residents and elopement. ADM stated she will send documentation of training to LPA by POC date, June 15, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/14/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Section Cited

87405 Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 06/15/2024
	Plan of Correction
1 2 3 4	ADM stated she will send a letter of understanding regading the regulation. ADM stated she will send the letter by POC date, June 15, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4