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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 10/16/2025
Date Signed: 10/16/2025 02:43:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20251008092313
FACILITY NAME:IVY PARK AT GLEN COVEFACILITY NUMBER:
486803921
ADMINISTRATOR:DEGUZMAN, SAMUELFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 653-4728
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 89DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tava Setareki, Business Office Director SpecialistTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not dispose of residents records properly.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a 10-day complaint investigation and deliver findings regarding the above allegation and met with Tava Setareki, Business Office Director Specialist (BODS).

Staff did not dispose of residents records properly – Reporting Party (RP) alleges that facility did not dispose of confidential resident documentation in a secured manner. During the course of this investigation LPA reviewed records, made observations, and conducted interviews. Review of photographs submitted by RP indicated that the confidential documents of multiple residents were disposed of in standard waste containers without maintaining resident confidentiality. Further review of photographs indicated that these waste containers were dumpsters. LPA located and observed that facility dumpsters are located outside of the facility in unlocked sheds. The dumpsters themselves were similarly unlocked.

Continued LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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 21-AS-20251008092313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT GLEN COVE
FACILITY NUMBER: 486803921
VISIT DATE: 10/16/2025
NARRATIVE
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Continued from LIC9099...

Improper disposal of resident records may allow access by unauthorized viewers to private information, based upon this there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid.

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D.

Exit interview conducted with BODS, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251008092313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: IVY PARK AT GLEN COVE
FACILITY NUMBER: 486803921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
CCR
87468.2(a)(2)
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Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement not met by licensee as evidenced by:
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Licensee to conduct staff training on proper disposal of confidential material in order to protect residents personal rights. Licensee to submit proof of training to CCL by COB on Plan of Correction due date of 11/14/2025.
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Licensee did not dispose of confidential resident records in a secure manner which poses a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3