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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 05/11/2026
Date Signed: 05/11/2026 03:05:14 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
03/09/2026 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20260309111015
FACILITY NAME:IVY PARK AT GLEN COVEFACILITY NUMBER:
486803921
ADMINISTRATOR:MOSES, CANDICEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 653-4728
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: DATE:
05/11/2026
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility did not follow elopement protocols
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator Candice Moses.

Facility did not follow elopement protocols – Responsible Party (RP) alleges that resident (R1) eloped from the facility to a busy intersection and was brought back by an individual who is not employed at the facility. During the course of this investigation LPA reviewed records, conducted interviews, and made observations. Review of Incident Report submitted by facility indicated that R1 eloped from the facility in the afternoon without staff knowledge. Review of LIC602 – Physician Report indicated that R1 is diagnosed with Dementia and is at risk if allowed to leave the community unsupervised. Six (6) of seven (7) staff interviewed indicated they were not fully aware of how R1 came back to facility, two (2) of seven (7) indicated they believed staff brought R1 back to the facility.

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

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
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 5
Control Number 21-AS-20260309111015
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: 05/11/2026
NARRATIVE
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Continued from LIC9099...

Interview with Administrator indicated that the resident was brought back by the family of a staff member, this individual was a not a staff member themselves, after seeing R1 along the side of a street and recognized them. Interviews with seven (7) of seven (7) staff indicated that in-service training on elopement has been given following incident. Based upon evidence gathered, 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 Administrator, whose signature on form confirms receipt.

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

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260309111015
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: 05/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2026
Section Cited
CCR
87411(a)
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Personnel Requirements – General 87411(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:
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Licensee has conducted in-service retraining to staff on elopement protocols. Deficiency cleared at time of visit.
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Based on interviews and file review, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of residents 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: 05/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/09/2026 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20260309111015

FACILITY NAME:IVY PARK AT GLEN COVEFACILITY NUMBER:
486803921
ADMINISTRATOR:MOSES, CANDICEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 653-4728
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: DATE:
05/11/2026
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility did not follow eviction protocol
Staff did not provide responsible party with admissions agreement
Staff did not provide resident or responsible party with reappraisal for alleged change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Administrator Candice Moses.

During the course of this investigation LPA reviewed records, conducted interviews, and made observations.

Facility did not follow eviction protocol – Responsible Party (RP) alleges that facility did not provide resident (R1) with a 30-day eviction or given a reason why R1 had to leave the facility. Interviews with management indicated that R1 was not provided with a 30-day eviction as R1 was not under eviction. Further interviews indicated that management believed R1 required a higher level of care in the facility due to new behaviors but R1’s family made the decision to take R1 out of the facility of their own accord.

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

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260309111015
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: 05/11/2026
NARRATIVE
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Continued from LIC9099A...

Staff did not provide responsible party with admissions agreement – RP alleges that an updated Admission Agreement was not provided upon Change of Ownership of facility. Review of facility information indicated that the facility has undergone a name change and has replaced management staff but has not completed a change of ownership. Following a Change of Ownership, facilities are not required to complete a new Admission Agreement for their residents and shall honor previous Admission Agreements upon resident requests.

Staff did not provide resident or responsible party with reappraisal for alleged change of condition – RP alleges that facility did not provide an updated appraisal following facilities claim of a change of condition. Review of documents indicated that R1 eloped on 2/27/2026 and was taken out of the facility by family on 3/2/2026. Further review of documents indicated that an Elopement Risk Assessment, Mini-Mental State Examination, and Behavioral Expression Appraisal were conducted on 2/27/2026 with an updated Service Plan drafted on the same date. Interviews with management indicated that R1 moved out before the updated Service Plan was implemented and R1’s family did not sign off on the Service Plan.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.

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

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5