Inspection Reports for
Ivy Park at Cathedral Hill

The facility was generally well maintained with proper lighting, safety features, and medication labeling. However, a deficiency was found where a resident's medication was ordered by a physician but the physical medication was not present in the centrally stored medication room.

The visit was triggered by complaint #14-AS-20250711142309 received on 2025-07-11. The deficiency cited was substantiated and previously cited on 2025-10-13. A Plan of Correction had been submitted and the deficiency was cleared during this visit.

The facility admitted a resident considered a fall risk but did not create a fall prevention plan to meet the resident's needs. A Type B citation was issued for this deficiency, which had been previously cited on 2025-10-13. The deficiency was cleared during this visit after a Plan of Correction was provided.

The visit was triggered by a complaint received on 10/14/2025 concerning medication management for resident R1. The complaint was substantiated by findings of failure to have physician orders and proper medication logging.

The investigation found that the licensee did not have a physician's order for medications provided by R1's responsible party, failed to log the medications, and did not contact the physician. This resulted in R1 not being provided safe, healthful, and comfortable accommodations. A Type B citation was issued for this deficiency.

The complaint was substantiated based on evidence that lack of supervision led to multiple falls and injuries of resident R1, and staff failed to report incidents as required. The preponderance of evidence standard was met.

The investigation substantiated that a resident (R1) fell multiple times resulting in serious injuries without an adequate fall prevention plan or documented safety checks. Additionally, staff failed to submit required written incident reports for 9 out of 10 falls within the mandated 7-day timeframe. An immediate civil penalty was issued.

The visit was complaint-related, closing an investigation into a self-reported incident where resident R1 was found deceased with a plastic bag over their head. The complaint involved failure to provide adequate supervision and care despite known suicidal ideations. The complaint was substantiated with findings of deficient care and oversight.

The investigation found that the facility failed to update the resident's care plan and increase supervision despite awareness of suicidal statements and a hospital visit. The Health Service Director and Executive Director did not ensure one-on-one care or increased checks, contributing to the resident's death. An immediate civil penalty was assessed.

The visit was complaint-related, triggered by a self-reported unusual incident involving resident R1 found deceased on 4/18/2024 after suicidal statements and refusal to eat. The complaint was substantiated with findings of inadequate care and supervision.

The investigation found that the facility staff and administration failed to update the resident's care plan and increase supervision after repeated suicidal statements, resulting in inadequate care and supervision that contributed to the resident's death. The Health Service Director and Executive Director did not ensure one-on-one care or increased checks were provided as required.

The visit was complaint-related, triggered by a self-reported incident on 06/07/2024 where staff intentionally blocked resident R1's bedroom door. The complaint was substantiated, and corrective action was taken by terminating the staff member.

The facility failed to ensure that resident room doors were unobstructed, violating the personal rights of resident R1. Staff member S1 intentionally placed a table in front of R1's door to prevent wandering, which was confirmed by investigation and staff interviews. The facility terminated the staff member and cited a deficiency.

The visit was complaint-related, following up on a self-reported incident where staff (S1) intentionally blocked resident R1's bedroom door. The deficiency was substantiated and corrective action included termination of staff S1.

The facility failed to ensure that residents' room doors were unobstructed, violating the personal rights of resident R1. Staff member S1 intentionally placed a table in front of R1's door to prevent wandering, which was confirmed by investigation and staff interviews.

The complaint investigation was substantiated for allegations that staff did not provide adequate supervision resulting in resident falls and did not respond to call buttons in a timely manner. The allegations that a resident was left on the floor for an extended period, staff did not observe resident's change of health conditions, and staff did not reassess resident's care plan were unsubstantiated.

The investigation substantiated that staff did not provide adequate supervision resulting in resident falls and did not respond timely to call buttons, with documented delays up to 289 minutes affecting 16 residents. Other allegations regarding leaving a resident on the floor and failure to observe or reassess care plans were unsubstantiated.

The complaint investigation substantiated allegations that staff did not provide adequate supervision resulting in resident falls and did not respond to residents' call buttons in a timely manner. The allegation that a resident was left on the floor for an extended period and that staff did not observe changes in health or reassess care plans were unsubstantiated due to lack of evidence.

The investigation substantiated that staff did not provide adequate supervision resulting in resident falls and failed to respond timely to residents' call buttons, with documented delays up to 289 minutes and 16 residents waiting over 30 minutes for assistance. Other allegations regarding failure to observe changes in resident health and reassess care plans were unsubstantiated due to lack of evidence.

The complaint was substantiated based on the preponderance of evidence standard. Staff failed to contact emergency personnel in a timely manner as alleged.

The complaint allegation that staff did not contact emergency personnel in a timely manner was substantiated. It was found that staff failed to call 911 immediately for a resident who was found unresponsive, resulting in a delay of approximately two hours before emergency services were alerted.

The complaint was substantiated based on interviews, observations, and record reviews. The allegations included failure to administer medication as prescribed and failure to respond to call buttons in a timely manner. Evidence showed medication discrepancies and delayed staff responses ranging from 55 to 120 minutes.

The investigation substantiated that staff failed to administer a resident's medication as prescribed due to a discrepancy between the physician's order, the medication administration record, and the pharmacy prescription bottle. Additionally, staff did not respond to resident call buttons in a timely manner, with documented delays ranging from 55 to 120 minutes.

The complaint investigation was substantiated based on evidence including interviews, observations, medication review, and call button response records. The complaint control number is 14-AS-20231128101756.

The investigation substantiated that there was a medication administration discrepancy involving Resident 1's Lamotrigine prescription and that staff failed to respond timely to residents' call buttons, with documented delays ranging from 55 to 120 minutes. A civil penalty was assessed for repeat violations.

The facility was generally clean and well-maintained with proper emergency supplies and locked medications. However, deficiencies were cited related to expired elevator inspections, missing updated medical assessments (LIC 602) in resident files, and incomplete resident appraisals. Plans of correction were requested with due dates.

The facility was generally clean and well-maintained with proper emergency supplies and locked medications. However, deficiencies were cited related to elevator inspections, missing updated medical assessments in resident files, and incomplete resident appraisals.

Complaint #14-AS-20230425173240 was investigated and substantiated based on the delayed staff response and failure to assist a resident after a fall.

The investigation found that on 4/20/2023, it took facility staff over 205 minutes to respond to a call cord after a resident fell, resulting in another resident assisting the fallen resident. This failure to provide timely assistance was cited as a deficiency under California Health and Safety Code LIC 809D.

Complaint #14-AS-20230425173240 was investigated and substantiated based on the delayed staff response to a resident fall and lack of assistance provided.

The investigation found that on 4/20/2023, a resident fell and it took facility staff over 205 minutes to respond to the call cord, resulting in another resident assisting the fallen resident. This failure to provide timely assistance posed an immediate health risk and was cited as a deficiency under California Health and Safety Code LIC 809D.

The complaint investigation was substantiated. The facility failed to meet a resident's dietary needs by serving food inconsistent with a physician's order and failed to respond timely to a resident's emergency call cord, resulting in a resident assisting another resident after a fall. The laundry services complaint was unsubstantiated.

The investigation substantiated that the facility failed to provide a prescribed mechanical soft diet to a resident and did not respond timely to a resident's emergency call cord, posing immediate health risks. The allegation regarding laundry services was unsubstantiated as the resident received laundry services from an agency as per the individual service plan.

The complaint was substantiated. The resident (R1) was served a diet not prescribed by the physician and staff failed to respond to an emergency call cord in a timely manner, resulting in R1 assisting a roommate (R2) who had fallen. The laundry services allegation was unsubstantiated.

The investigation substantiated that a resident was served a diet not prescribed by the physician, including raw vegetables despite a mechanical soft diet order, and that staff failed to respond timely to an emergency call cord, resulting in a resident assisting another after a fall. Another allegation regarding laundry services was unsubstantiated.

The visit was complaint-related due to an abuse allegation involving staff blocking a resident and punching the resident's abdominal area. The complaint was substantiated as the facility failed to ensure timely reporting and required staff training.

The facility failed to ensure the safety of a resident due to delayed reporting of an abuse incident by staff and failure to ensure required staff training on abuse and neglect. Deficiencies were cited under California Code of Regulations, Title 22.

The complaint investigation found that staff #1 witnessed abuse but did not report it until 8 days later, and the facility did not ensure staff #1 received required training. The facility was cited under California Code of Regulations, Title 22, LIC 809D.

The facility failed to ensure the safety of resident #1 as the abuse incident was reported 8 days late by staff #1, and the alleged abuser was assigned to care for the resident one more time before being placed on administrative leave. Additionally, staff #1 did not receive required training on Abuse and Neglect.

The complaint was substantiated regarding medication mismanagement due to failure to follow up on medication refills, causing delays in medication administration from 10/11/2022 to 10/16/2022. The allegation that staff were not properly trained was unsubstantiated.

The investigation substantiated that the facility failed to administer two prescribed medications to resident #1 for several days due to lack of follow-up with the pharmacy and physician for refills, resulting in delayed medication delivery and administration. The allegation regarding staff training was unsubstantiated as staff were able to articulate proper procedures, though they failed to follow through on them, contributing to the delay.

The complaint was substantiated regarding medication mismanagement due to failure to follow up on medication refills from 10/11/2022 to 10/16/2022, causing delayed medication delivery and administration. The allegation that staff were not properly trained was unsubstantiated.

The investigation substantiated that the facility staff failed to properly follow through with medication refills for resident #1, resulting in delayed administration of two prescribed medications. However, the allegation that staff were not properly trained was unsubstantiated as staff were able to articulate proper procedures, though they failed to follow up timely.

The complaint investigation was substantiated based on evidence including staff interviews, observations of unclean rooms and unsanitary conditions, and review of staff assignment sheets showing multiple open shifts and uncovered shifts in the memory care unit.

The investigation substantiated the allegations, finding multiple open staff shifts, insufficient staffing especially in the memory care unit, and poor cleanliness including uncleaned resident rooms and unsanitary conditions. The facility was found to be unkempt, unsanitized, and uncomfortable for residents.

The complaint alleged that staff did not respond timely to a resident's call for assistance after an injury and did not seek medical attention promptly. The allegation of delayed response was substantiated, while the allegation regarding medical attention was unsubstantiated.

The investigation substantiated that staff did not respond in a timely manner to resident #1's call for assistance after a fall at 1 AM, with staff responding only at 3 AM, posing an immediate health risk. Another allegation that staff did not seek medical attention in a timely manner was unsubstantiated as the resident declined hospital care.

The complaint investigation was substantiated based on evidence including staff interviews, observations of unclean resident rooms, multiple uncovered shifts, and insufficient staffing in the memory care unit. The facility was found to be unkempt and unable to provide a safe and comfortable environment for residents.

The investigation substantiated the allegations that the facility had insufficient staffing, especially in the memory care unit, multiple open shifts, and staff working overtime. The facility was found to be unkempt with dirty resident rooms and unsanitary conditions, and overall failed to provide a safe, clean, and comfortable environment for residents.

The complaint investigation was substantiated regarding delayed staff response to resident's call for assistance after injury. The allegation that staff did not seek medical attention in a timely manner was unsubstantiated.

The investigation substantiated that staff failed to respond to resident #1's call pendant for assistance for approximately two hours after a fall, posing an immediate health risk. However, the allegation that staff did not seek medical attention in a timely manner was unsubstantiated as the resident declined hospital care.

The inspection found that two residents who tested positive for COVID-19 were participating in activities with non-affected residents without face coverings, and staff were unaware of their positive status. Additionally, the facility failed to report positive COVID-19 cases to the licensing agency within 24 hours as required.

The inspection found that two residents who tested positive for COVID-19 were participating in activities with non-affected residents without face coverings, and staff were unaware of their positive status. Additionally, positive COVID-19 cases were not reported to the licensing agency within the required 24-hour timeframe.

The complaint investigation was substantiated for failure to notify the resident's responsible party in a timely manner. The allegation regarding a resident fall resulting in fracture was unsubstantiated.

The investigation substantiated that the facility failed to notify the correct responsible party of a resident's change in condition and hospitalization due to outdated records. Another allegation regarding a resident fall resulting in fracture was found unsubstantiated as the facility followed protocols. A deficiency related to personal rights was cited.

The complaint investigation found that staff did not notify resident #1's responsible party of an incident in a timely fashion due to outdated information in the resident's paper chart. The complaint was substantiated with a deficiency cited under California Code of Regulations, Title 22, LIC 809D.

The facility failed to ensure that resident #1's current record was maintained accurately, resulting in staff contacting the former responsible party instead of the updated one, which led to the responsible party not being informed of the resident's change of condition.

The complaint investigation was substantiated for failure to notify the responsible party timely due to outdated face sheet information, but unsubstantiated for the allegation of resident fall resulting in fracture.

The investigation substantiated that staff failed to notify resident #1's responsible party of a change in condition and hospitalization in a timely manner due to outdated records. Another allegation that a resident suffered a fall resulting in fracture was found unsubstantiated as the facility followed protocols and the fall was accidental.

The complaint investigation was substantiated for failure to properly report a resident's change of health condition to the responsible party. The allegation that staff caused injuries to a resident during transfer was unsubstantiated.

The investigation substantiated the allegation that staff did not properly report a resident's change of health condition to the responsible party, posing a potential health risk. The facility conducted an in-service on Incident Reporting Protocols as part of the plan of correction. The allegation that staff caused injuries to a resident during transfer was unsubstantiated based on interviews and observations.

Complaint #14-AS-20220520135606 was investigated and substantiated as the facility failed to ensure resident #1's current record was maintained, leading to failure to notify the responsible party of a change in condition.

The investigation found that the facility did not maintain the current record for resident #1, resulting in the responsible party not being informed of the resident's change of condition. This was due to the updated responsible party information not being printed in the resident's paper chart.

The visit was complaint-related, investigating complaint #14-AS-20211214115249. The complaint was substantiated as the facility failed to provide alternate accommodations during hot water pump repair.

The facility failed to ensure residents were provided with comfortable and healthful accommodations during the repair of the hot water pump, as 7 out of 7 residents reported not being offered an alternate location for hot showers.

The visit was triggered by complaint #14-AS-20211214115249. The complaint was substantiated as the facility failed to provide alternate accommodations for hot showers during repairs.

The facility failed to ensure residents were provided with comfortable and healthful accommodations during the repair of the hot water pump, as residents were not offered an alternate location for hot showers and had to make their own arrangements.

Complaint investigation was unsubstantiated. The allegation that the facility was in disrepair due to lack of hot water and failure to provide alternate shower locations or proper communication was investigated. The facility responded promptly and communicated with residents, but did not offer alternate shower locations. The overall allegation was unsubstantiated.

The investigation found that the facility did experience a hot water outage from 12/2/21 to 12/14/21 due to a malfunctioned circulator hot water pump. The facility acted promptly to address the issue, but the repair was delayed due to a part shipment from another state. Residents were offered hot showers in unaffected apartments and received updates via a broadcast system. However, residents were not offered an alternate location for hot showers during the repair. The allegation was ultimately unsubstantiated due to insufficient evidence of violations.

The complaint was unsubstantiated. The facility did not have hot water for several days due to a malfunctioning circulator hot water pump. The facility acted promptly to address the issue, but the repair was delayed due to a part shipment. Residents received updates but were not offered alternate shower locations.

The investigation found that the facility did experience a hot water outage due to a malfunctioning circulator hot water pump, and the repair was delayed due to a part shipment from another state. Residents were offered hot showers in unaffected apartments and received updates via a broadcast system. However, residents were not offered an alternate location for hot showers during the repair. The allegation was ultimately unsubstantiated due to insufficient evidence of violations.

The complaint investigation was initiated based on allegations received on 01/16/2020. The investigation included interviews and record reviews. Some allegations were found to be unfounded or unsubstantiated, while others were substantiated. The substantiated allegations involved unexplained injury to a resident and failure to assist with eating. Deficiencies were cited accordingly.

The investigation found some allegations to be unfounded or unsubstantiated, such as failure to provide medical care and timely notification, facility disrepair, and cleanliness issues. However, two allegations were substantiated: a resident sustained an unexplained injury while in care, and staff failed to adequately assist a resident with eating, posing a potential health and safety risk.