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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804017
Report Date: 11/22/2022
Date Signed: 11/22/2022 10:06:24 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/31/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220531090701
FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:BOOTH, KEVINFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 79DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lydia GravelynTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained an unwitnessed fall resulting in injuries while in care.
Resident sustained skin tears while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Lydia Gravelynand discussed findings. This Department has investigated allegations by conducting interviews; reviewing documents and photographs; making site visits to facility. The following determinations are made: R1 sustained unwitnessed fall on 1/19/2022; initial assessment of 1/11/2022 notes R1 can transfer independently and does not require assistance; Staff report that R1 had been checked prior to fall within the hour; Staff summoned medical attention and made the required notifications. On 5/17/2022, staff noted a fresh skin tear on R1; Facility LVN assessed and dressed the tear and made required notifications; Seen by a MD on 5/23/2022, R1 was noted to have no signs of infection or abuse; MD reports that the injury consistent with a fall. This Department has investigated the complaint allegations and, based upon the statements taken and documents reviewed, we have determined that the complaint is UNFOUNDED, meaning that the allegations are false and/or, are without a reasonable basis. The complaint is DISMISSED. Report left.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/31/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220531090701

FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:BOOTH, KEVINFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 79DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lydia GravelynTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Medical attention was not sought for resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Lydia Gravelyn and discussed findings. This Department has investigated allegations by conducting interviews; reviewing documents and photographs; making site visits to facility. The following determinations are made: R1 was observed to have excessively long toenails and with cracked, dry skin on feet which was not treated for a prolonged period of time; Facility management states that the regularly scheduled podiatrist was out for several months due to Covid and that family was not in the area to assist in obtaining care for R1’s feet. Based upon the statements and photographs, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220531090701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: IVY PARK AT SANTA ROSA
FACILITY NUMBER: 496804017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based upon statements and photographs this requirement has not been met as evidenced by: Facility failed to arrange timely podiatric care for
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Facility Management will provide a written plan which outlines action to be taken by facility going forward which addresses how residents’ podiatric needs will be timely met, including circumstances when family is not available to transport and/or, provide the care. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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R1 which resulted in excessively long nails and toes in need of care. This posed an immediate risk to the health and personal rights of the resident 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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/31/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220531090701

FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:BOOTH, KEVINFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 79DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lydia GravelynTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident was physical abused while in care
Resident hygiene needs were not met resulting in wound/infection of foot
Medical documentation regarding resident was not maintained properly
Resident suffered malnutrition while in care
Resident’s representative was not informed of resident’s change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Lyn Gravely and discussed findings. This Department has investigated allegations by conducting interviews; reviewing documents and photographs; making site visits to facility. The following determinations are made: Although R1 reportedly exhibited negative response to caregivers, no substantial evidence was found to support physical abuse; reviewed medical reports do not indicate R1 had an infected wound on R1’s foot; Review of Medical Administration Records and chart notes indicate that medical documentation of R1’s care conforms to Title Twenty-Two regulations; R1 lost substantial amount of weight while in care; chart notes and statements indicate R1 was a reluctant eater, often refusing food, and was taking medications identified as suppressing appetite; Chart notes and Serious Incident Reports reviewed by Department indicate R1’s representative was given notices as required by regulation. Although the allegations may be true, based on the records reviewed and statements taken, there is not a preponderance of evidence to prove the allegations are, or are not, true. Therefore, the complaint is UNSUBSTANTIATED.
No citations issued. Report left at facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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 4