079201116-9-26-2025-15-AS-BFOG-DMF672-20251013203249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201116
Report Date: 09/26/2025
Date Signed: 09/26/2025 10:35:50 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230824130321

FACILITY NAME:	IVY PARK AT SAN RAMON		FACILITY NUMBER:	079201116
ADMINISTRATOR:	COONS, JENNIFER S		FACILITY TYPE:	740
ADDRESS:	9199 FIRCEST LANE		TELEPHONE:	(949) 744-5200
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	162	CENSUS: 146	DATE:	09/26/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jones Thaleana, Business Office Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are not safeguarding residents' medications
Staff did not administer resident's medications as prescribed

INVESTIGATION FINDINGS:

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On 9/26/2025 at 9:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver findings regarding the allegations above. LPA met with the Business Office Director, Jones Thaleana. Executive Director (ED) Gilbert Castro informed them of the reason for the visit. ED was not available during the time and gave verbal permission to the Business Office Director to sign the report
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It was alleged that Staff are not safeguarding residents' medications- Substantiated

During the investigation, LPA conducted interviews and reviewed files. LPA reviews the photo, which shows R1 medication was left on the table on Aug 23. 2023 at 11:24 am. LPA reviewed the R1 Physician report, which indicates that R1 is unable to manage their own medication. On Aug 31. 2023 LPA interviewed staff and attempted to interview residents. S4 stated that S4 did not remember going back to the R1 room to pick up the medication left on the dresser. S1 stated that there’s a one-hour gap that MED-Tech can go back to retrieve the medication or witness residents take the medication. S3 admitted that S4 forgot to pick up the medication in the R1 room.

Report continues on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230824130321

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT SAN RAMON	FACILITY NUMBER: 079201116
	VISIT DATE: 09/26/2025

NARRATIVE

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It was alleged that the Staff did not administer the resident's medications as prescribed- Substantiated

During the course of investigation, LPA interviewed staff, record review, and other evidence gathered during the investigation, the allegation that staff did not administer the resident’s medications as prescribed was found to be substantiated. Records indicate that staff failed to follow the physician’s orders regarding medication administration, resulting in missed and/or delayed doses. This practice poses a potential health and safety risk to residents in care.

The following deficiencies were observed see LIC 809D and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

An exit interview was conducted, and a copy of this report and appeal rights is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20230824130321

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT SAN RAMON	FACILITY NUMBER: 079201116
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 10/10/2025 Section Cited HSC 87465(h)(2)	1 2 3 4 5 6 7	87465(h)(2) Incidental Medical and Dental Care “Once ordered by the physician, medications shall be given according to the physician’s directions.” Residents’ medications must be safeguarded to ensure they are administered only to the prescribed individual and strictly in accordance with the physician’s directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall immediately implement corrective measures to ensure all medications are stored securely and accessible only to trained staff. The licensee shall retrain staff on medication safeguarding policies and procedures. Documentation of staff training and photographs of corrected storage practices shall be submitted to Community Care Licensing by 10/10/2025.
	8 9 10 11 12 13 14	Based on observation and record review, the licensee did not ensure the safeguarding of residents’ medications. Medications were found unsecured and accessible, creating a risk that residents may receive medications not prescribed to them or that doses may not be administered as directed. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Under Appeal Type B 10/10/2025 Section Cited HSC 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) – Personal Rights of Residents in All Residential Care Facilities for the Elderly “To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” Residents shall be provided with safe, healthful, and comfortable accommodations, which includes the proper administration of prescribed medications to ensure resident health and safety. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall provide immediate retraining for all staff responsible for medication administration, with emphasis on adherence to physician’s orders and proper medication administration procedures. Proof of completed staff training, including attendance records and training materials, shall be submitted to Community Care Licensing by 10/10/2025.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure that medications were administered as prescribed. Documentation confirmed that staff failed to follow physician’s orders regarding medication administration, resulting in missed and/or delayed doses. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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