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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 07/10/2026
Date Signed: 07/10/2026 02:34:00 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
06/25/2026 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20260625120926
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: 130DATE:
07/10/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not distribute resident's medication as prescribed
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.

Staff do not distribute resident's medication as prescribed – Reporting Party (RP) alleges that resident (R1) did not receive medication as prescribed for multiple days. During the course of this investigation LPA conducted interviews and reviewed records. Review of R1 Medication Administrator Record (MAR) indicated one hundred (100) or more instances of medications not being distributed. Review of Exceptions note indicated the most consistent reason for medication not being distributed is due to “medication not available”. Interviews with management indicated that R1’s medication is not delivered to the facility and is instead delivered to POA. Further interviews with management indicated that the facility will contact POA to bring R1’s medication but this will often take many days.

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

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
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-20260625120926
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: 07/10/2026
NARRATIVE
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Continued from LIC9099...

Further review of R1’s MAR indicated numerous inconsistencies with medication marked “not available” for multiple days in a row followed by one (1) to four (4) days of medication being administered, and then multiple more days of medication “not available”. MAR indicates this cycle continuously repeats. Interviews with management could not explain these inconsistencies. Interview with RP indicated that medication inconsistencies had been caught early on and attempts to rectify them yielded no results. Review of communication with R1’s hospital indicated numerous instances of physicians/pharmacists not being informed of medication running out. Further review of communication between facility management and hospital indicated the incorrect physician was often being informed of the need for refills, leading to medication not being refilled on time. 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: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260625120926
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: 07/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2026
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement not met by Licensee as evidenced by:
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Licensee shall submit a plan on how they will ensure medication is filled and dispensed as prescribed by Plan of Correction due date of 7/13/2026 by 5:00PM.
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Based upon file review and interviews, R1 was not dispensed medication according to the physician's directions which poses/posed 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: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
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
06/25/2026 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20260625120926

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: 130DATE:
07/10/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not maintain accurate records
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.

Staff do not maintain accurate records – Reporting Party (RP) alleges that facility medication log is not being accurately maintained for R1. Review of MAR indicated that medication distribution is marked with either an X, staff initials, or staff initials that have been circled. Interview with management indicated that X denotes medication that has not been started, staff initials denote medication that was given, and circled staff initials denote medication that was not given with reasoning noted on medication Exceptions page. Review of MAR and Exceptions page indicated that medication distribution is being accurately logged, and each Exception has a corresponding note.

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

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
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-20260625120926
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: 07/10/2026
NARRATIVE
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Continued from LIC9099A...

Further review of R1’s file indicated that documentation is being properly kept and stored, including Title 22 required forms. Inconsistencies with documentation of medication distribution has been included on allegation “Staff do not distribute resident's medication as prescribed”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is 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: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5