Inspection Reports for Ivy Park at San Ramon

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-07-29, including staff not providing timely assistance to residents and facility disrepair.

The investigation substantiated that staff did not provide timely assistance to a resident due to a malfunctioning call button and that the facility was in disrepair. Additionally, allegations regarding staff charging residents for services not rendered, not following care plans, and inappropriate communication were found unsubstantiated.

The complaint investigation was substantiated for allegations that staff did not provide assistance to a resident in a timely manner and that the facility was in disrepair. The allegations that staff charged residents for services not rendered, did not follow residents' care plans, and spoke inappropriately to residents were unsubstantiated.

The inspection was conducted as a result of a priority 1 complaint to perform a Health & Safety inspection at the facility.

The inspection found that the hot water temperature in one resident room was 126.1 degrees F, exceeding the allowed maximum of 120 degrees F, posing an immediate safety risk. A civil penalty of $250 was assessed for repeat violations.

The visit was triggered by a priority 1 complaint. The complaint was substantiated as the hot water temperature violation was confirmed during the inspection.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-03-10 regarding medication assistance, refusal to accept a resident back, and denial of access to resident records.

The investigation substantiated that staff did not provide proper medication assistance to a resident, identifying errors in medication administration documentation. However, allegations that staff refused to accept a resident back and denied access to resident records were unsubstantiated due to lack of evidence.

The complaint investigation was substantiated for improper medication assistance but unsubstantiated for refusal to accept resident back and denial of access to resident's records. The medication error involved marking medication as given when it was not administered due to system and human errors. The other allegations lacked sufficient evidence.

The inspection visit was a case management visit conducted as a result of a self-reported incident involving an alleged injury between two residents on 7/23/2025.

The Licensing Program Analyst found no evidence to support the allegation that resident R2 hurt resident R1. R2 was non-ambulatory and unable to commit the alleged act. The police and responsible party were notified, and R1's condition and care plan were updated. No deficiencies were cited during the visit.

The visit was a case management visit conducted as a result of delivering an amended complaint report for complaint #15-AS-20241203085000.

No deficiencies were cited during the visit. An exit interview was conducted and a copy of the report was provided to the facility.

The visit was related to complaint #15-AS-20241203085000 and involved delivery of an amended complaint report.

The inspection visit was conducted as a case management visit following an elopement incident involving a memory care resident (R1) that occurred on 2025-06-25.

The facility failed to prevent the elopement of resident R1 and did not report the incident within the required 24-hour timeframe. The elopement posed an immediate safety risk to residents in care.

The visit was triggered by a complaint related to an elopement incident of resident R1 on 2025-06-25. The complaint was substantiated as the facility failed to prevent the elopement and failed to report it within 24 hours.

The inspection was conducted as a result of a priority 1 complaint to assess health and safety conditions at the facility.

The Licensing Program Analyst toured the facility and found no deficiencies. All safety measures, including hot water temperature, food supplies, medication storage, smoke detectors, carbon monoxide detector, first-aid kit, and fire extinguisher, were in compliance.

The visit was triggered by a priority 1 complaint. No deficiencies were cited during the inspection.

The inspection was an unannounced complaint investigation visit triggered by allegations of staff mismanaging residents' medications, failure to notify residents and responsible parties, and untimely response to residents' call buttons.

The investigation substantiated the allegations, finding multiple medication administration errors, malfunctioning call button systems, failure to notify families about care costs, discrepancies in residents' care plans, and failure to send incident reports as required. The facility was found to be in disrepair and not fully compliant with care and reporting regulations.

The complaint investigation was substantiated based on interviews, record reviews, and observations. The allegations included medication mismanagement, failure to notify residents and responsible parties, untimely response to call buttons, facility disrepair, failure to send incident reports, and noncompliance with residents' care plans.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-02-10 regarding allegations including staff not ensuring a resident has hot water and not abiding by the admission agreement.

The allegation that staff did not ensure a resident had hot water was substantiated; the facility had an issue with hot water in one of the resident's bathrooms for a few months, which was resolved by replacing the boiler system. The allegation that staff did not abide by the admission agreement was unsubstantiated as the admissions agreement did not include wifi, which was a courtesy service.

The complaint investigation was substantiated for the allegation that staff did not ensure a resident had hot water, but unsubstantiated for the allegation that staff did not abide by the admission agreement.

The inspection was an unannounced complaint investigation visit conducted due to multiple allegations including facility disrepair, staff not following residents' care plans, failure to send incident reports as required, and staff not providing medication as prescribed.

The investigation substantiated the allegations that the facility was in disrepair, staff were not following residents' care plans, incident reports were not sent as required, and medication was not always administered as prescribed. Specific issues included non-operational fireplaces, broken washers and dryers, malfunctioning call button systems, inaccurate medication administration records, and discrepancies in residents' care plans. Some allegations regarding cleanliness, staffing adequacy, and controlled substance administration were found to be unsubstantiated.

The complaint investigation was substantiated for allegations of facility disrepair, staff not following care plans, failure to send incident reports, and medication administration errors. The allegations regarding facility cleanliness, adequacy of care, staffing levels, and controlled substance administration were unsubstantiated due to lack of evidence.

The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing regulations.

The inspection found that the facility's fire clearance was approved for 162 residents, with adequate lighting, temperature, and safety features. However, deficiencies were noted including hot water temperature exceeding regulatory limits and staff lacking current first aid training.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-10-07 regarding staff privacy violations and theft of resident items.

The investigation included interviews, file reviews, and evidence requests. No substantiated evidence was found to support the allegations, and no deficiencies were cited. The allegations were determined to be unsubstantiated.

The complaint involved allegations that staff did not accord residents' privacy and stole items from residents. The investigation found no disciplinary actions against the accused employee, no police records, and no reports of missing items. The employee resigned after harassment. The allegations were unsubstantiated due to lack of evidence.

The visit was conducted as a case management visit resulting from an Unusual Incident Report received on 2024-08-09 regarding a resident's unsafe behaviors shortly after admission.

The investigation found that the resident exhibited unsafe behaviors inconsistent with prior assessments, was diagnosed with unspecified schizophrenia, and no injuries occurred. The facility retrained staff on elopement procedures. No deficiencies were cited during the visit.

The complaint involved a resident climbing walls, entering neighboring homes, running into the street, and other unsafe behaviors shortly after moving in. The resident was found to have a prior physician's report indicating independence, but was later diagnosed with unspecified schizophrenia and no longer resides at the facility.

The inspection was an unannounced case management visit conducted as a result of an Unusual Incident Report received on 2024-07-22 regarding a theft incident involving a resident's personal belongings.

The investigation found that a staff member (S1) stole a resident's (R1) purse, phone, wallet, and contents. S1 has been terminated. No deficiencies were cited during the visit. The facility retrained staff on reporting requirements and procedures.

An unannounced complaint investigation visit was conducted following a complaint received on 2024-06-03 regarding blocked fire exits and other safety concerns.

The investigation substantiated that a fire exit in the stairwell behind door 6 was blocked by a shampoo machine, posing an immediate health and safety risk. Other allegations regarding emergency disaster plans, evacuation chairs, and emergency drills were found unsubstantiated.

The complaint investigation was substantiated for the allegation that the fire exit was blocked. Other allegations about emergency disaster plan, evacuation chairs, and emergency drills were unsubstantiated.

The inspection was an unannounced continuation of the 1-Year Annual Required inspection to evaluate compliance with licensing regulations and fire clearance.

The inspection found multiple deficiencies including a resident designated as bedridden residing in a room not cleared for bedridden persons, staff lacking required first aid training, and missing health screenings or TB results in staff files. An immediate $500 civil penalty was assessed for the fire clearance violation.

The visit was an unannounced Case Management visit in response to an unusual incident report received on 2024-02-06 regarding an alleged physical abuse incident involving a resident in memory care.

It was found that on 2024-01-31, a staff member (S1) pushed a resident (R1) in memory care, constituting physical abuse. The resident had no visible injuries and was unable to recall the event. The facility provided training to staff on mandated reporting requirements following the incident.

The visit was complaint-related due to an unusual incident report alleging physical abuse of a resident by a staff member. The allegation was substantiated based on interviews and reports.

The visit was conducted as a Case Management visit in response to an unusual incident report received on 2024-02-06 regarding an alleged staff push of a resident in memory care.

The investigation found that the resident had no injuries or recollection of the event, and the staff member alleged of abuse was terminated effective 2024-02-12. No deficiencies were cited at this time.

The complaint involved an allegation that a staff member pushed a resident. The resident was assessed with no visible injuries and was unable to recall the event. The staff member was terminated. The investigation is ongoing with a planned return visit.

The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.

The Licensing Program Analyst toured the facility and found adequate lighting, appropriate temperature, safe hot water temperatures, and proper safety equipment in residents' bathrooms. No citations were issued during the inspection. The annual inspection was incomplete and will be continued at a later date.

The visit was an unannounced Case Management visit conducted in response to an unusual incident report received on 11/11/2023 regarding a resident who went AWOL from the facility.

The Licensing Program Analyst reviewed the resident's physician report and care plan, which stated the resident was able to leave the facility unassisted. The incident involved the resident leaving their apartment and being found in the parking lot shortly after the door alarm sounded.

An unannounced complaint investigation was conducted in response to allegations of facility disrepair and malodorous conditions.

The investigation found that the exhaust fans in the kitchen were broken for about a week, causing odors. The facility has taken actions to alleviate the odor and is awaiting repairs. Based on observations and interviews, the allegations were determined to be unsubstantiated as the facility is actively addressing the issues.

The complaint investigation was unsubstantiated. Allegations included facility disrepair and malodorous conditions. The facility was found to be taking corrective actions such as contacting repair services and ventilating the kitchen area.

The inspection was an unannounced Case Management visit conducted to evaluate compliance with facility regulations, specifically related to fire clearance capacity.

The facility was found to be over its approved fire clearance capacity, housing 143 residents while the approved capacity is 140. This posed an immediate health, safety, or personal rights risk and resulted in a civil penalty.

An unannounced complaint investigation was conducted in response to an allegation that staff do not ensure residents' special dietary needs are being met.

The investigation found that the facility does not provide gluten free options such as gluten free breads and pastas, and was unable to accommodate all prescribed diets, including a doctor's order for a resident's gluten and lactose free diet. The allegation was substantiated.

The complaint was substantiated based on the preponderance of evidence standard. The allegation was that staff do not ensure resident's special dietary needs are met, specifically regarding gluten and lactose free diets.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-03-15 regarding allegations including medication not administered timely, insufficient staff, staff yelling at residents, and inadequate care.

The investigation substantiated that facility staff failed to administer a resident's medication as ordered, posing an immediate health and safety risk. Other allegations regarding insufficient staff, staff yelling at residents, and inadequate care were unsubstantiated based on interviews, observations, and record reviews.

The complaint investigation was substantiated for the allegation that facility staff did not administer medication in a timely manner. Other allegations including insufficient staff, staff yelling at residents, and inadequate care were unsubstantiated.

The inspection visit was conducted as an unannounced complaint investigation regarding allegations that facility staff engaged in food preparation and service did not protect resident meals from contamination.

The investigation found that although there was an outbreak of norovirus at the facility, interviews with residents indicated symptoms were not due to food poisoning. There was insufficient evidence to substantiate the allegation, and it was determined to be unsubstantiated.

The complaint alleged that facility staff did not protect resident meals from contamination. The allegation was unsubstantiated due to lack of preponderance of evidence.

Unannounced complaint investigation visit conducted due to allegations that the facility failed to provide a safe environment for a resident, did not report an incident to an authorized representative in a timely manner, and did not call 911 in a timely manner.

The investigation found that maintenance for heating and air conditioning units was conducted quarterly, with the last maintenance on 7/30/22. Staff interviews and record reviews showed that the facility contacted the responsible party and emergency contacts appropriately and called 911 immediately upon being informed of the incident. There was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.

The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.

The inspection was conducted as a Case Management visit resulting from complaint #15-AS-20221104082159 to investigate compliance with fire safety regulations.

A deficiency was found where the facility did not have smoke detectors monitored by a fire alarm company, posing a potential health and safety risk to residents. The facility was cleared by the Fire Marshall on 11/10/22.

The visit was triggered by complaint #15-AS-20221104082159. The deficiency related to fire safety was substantiated based on record review and interview.

The visit was an unannounced pre-licensing inspection conducted to evaluate the facility's readiness for licensing.

No issues were noted during the inspection. The facility was found to be ready to be licensed, with proper furniture, safety equipment, and fire clearance in place.

The visit was conducted as part of a Change of Ownership (CHOW) application process for licensing evaluation of the facility.

The applicant and administrator participated in a telephone call to confirm understanding of Title 22 regulations, facility operation, staff qualifications, program policies, and other licensing requirements. The evaluation included review of application documents, health screening, fire clearance, and COVID-19 mitigation plan discussion.

The visit was conducted as part of a Change of Ownership (CHOW) application process for licensing evaluation of the facility.

The applicant and administrator demonstrated understanding of Title 22 requirements including facility operation, staff qualifications, program policies, and COVID-19 mitigation plan. The evaluation included review of health screening, fire clearance, certifications, financial verification, and compliance history.