<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202929
Report Date: 07/03/2025
Date Signed: 07/03/2025 11:48:22 AM

Document Has Been Signed on 07/03/2025 11:48 AM - 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:
435202929
ADMINISTRATOR/
DIRECTOR:		BRICE, STEPHANIEFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO ROADTELEPHONE:
(650) 326-1108
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY: 97CENSUS: 67DATE:
07/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Stephanie BriceTIME VISIT/
INSPECTION COMPLETED:
12:00 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
On July 03, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 06/20/2025 when the resident (R1) eloped from the facility. Upon arrival, LPA met with the Executive Director (ED), Stephanie Brice, and disclosed the purpose of the visit.

LPA interviewed one (1) staff member: ED, and one (1) resident (R1).

The ED stated that on 06/20/2025, at approximately 7 PM, S1 responded to the first-floor stairwell exit alarm. S1 did not see anyone around the exit, so S1 immediately called out on the walkie-talkie for the team to start apartment checks to ensure all residents were accounted for. At approximately 7:05 PM, S1 reported to the ED that R1 could not be located. Apartment checks continued, and other facility staff members began searching the outside areas and the immediate neighborhood. ED stated R1 lives on the fourth floor, and they are not sure if R1 took stairs from the fourth or any other floor.

ED stated that at approximately 7:10 PM, the facility received a call from R1's former Physical Therapist (PT), who stated that R1 was with them and that they were bringing R1 back to the community. The ED contacted R1’s Responsible Party (RP) to inform them about the incident. R1 was brought back to the community. The PT informed the ED that they had seen R1 at the corner of El Camino and California Avenue. R1 stated that they had gone for a walk but forgot how to get back.

ED stated that before the elopement incident on 06/20/2025, R1 was not wearing a safety bracelet. But after R1 returned, the facility ensured that R1 is wearing wander guard bracelet all the time. Med techs are checking three times a day to ensure R1 is wearing a wander guard bracelet.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 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 PALO ALTO
FACILITY NUMBER: 435202929
VISIT DATE: 07/03/2025
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
26
27
28
29
30
31
32
LPA reviewed R1’s Physician’s Report (LIC 602), dated 03/30/2025, R1 was non-ambulatory, had a primary diagnosis of Alzheimer's Dementia, was deemed not able to leave the facility unassisted.

LPA reviewed R1’s Individualized Service Plan (ISP), dated 04/01/2025, which stated that R1 was ambulatory and unable to leave the community unsupervised. The ISP further stated that R1 was required to wear a safety bracelet while residing in the Assisted Living.

LPA conducted a health and wellness check on R1 by visiting R1’s room. R1 stated that they did not have any recollection of whether they had exited the building alone without anyone accompanying them. R1 also stated that they liked to walk outside and inside the facility and use the elevators to go down to the first floor.

R1 resided in the Assisted Living unit of the facility and was not wearing a safety bracelet at the time of the elopement. Facility staff did not ensure that R1 didn’t leave the facility unaccompanied, and a safety bracelet was not placed on R1’s arm prior to the elopement incident. Facility staff placed a wander guard bracelet on R1 only after the elopement incident occurred on 06/20/2025.

A deficiency was cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Executive Director. A copy of this report and appeal rights were discussed and provided to the Executive Director, Stephanie Brice, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/03/2025 11:48 AM - It Cannot Be Edited


Created By: Kiran Jain On 07/03/2025 at 11:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT PALO ALTO
FACILITY NUMBER: 435202929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2025
Section Cited
CCR
87411(a)

1
2
3
4
5
6
7
87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The ED will submit a POC plan to ensure that R1 wears a wander guard bracelet and is safe all the time. The ED will provide a copy of the plan to CCLD by 07/04/2025.
8
9
10
11
12
13
14
The facility staff were not able to prevent the resident (R1) from eloping the facility. R1 has dementia, is deemed not able to leave the facility unassisted, and was able to leave the facility unaccompanied around 7 PM on 06/20/2025, which posed an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4