Inspection Reports for
Ivy Park at San Ramon

The complaint investigation (15-AS-20250820161102) substantiated that the facility failed to provide adequate care and supervision, specifically in monitoring residents during mealtime in memory care.

The investigation found that on 08/13/2025, a resident (R2) entered another resident's (R1) room without staff knowledge during mealtime due to lack of monitoring of residents being brought to dining. This indicated insufficient staffing in memory care, posing a potential personal rights violation.

The complaint was substantiated. The allegation that staff did not give the resident's responsible party proper notification of the resident's room change was confirmed based on evidence including interviews and record reviews.

The allegation was substantiated based on interviews, record reviews, and observations. The facility failed to provide a written 30-day notice of the room change to the responsible party, violating personal rights regulations.

The complaint investigation was substantiated. Allegations included staff not safeguarding residents' medications and not administering medications as prescribed. Evidence included interviews, record reviews, and photographic evidence of unsecured medication.

The investigation substantiated that staff failed to safeguard residents' medications and did not administer medications according to physician's orders, resulting in missed or delayed doses and posing a potential health and safety risk to residents.

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 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 due to a malfunctioning call button and that the facility was in disrepair. Other allegations including staff charging residents for services not rendered, not following care plans, and inappropriate communication were unsubstantiated.

The investigation substantiated that a resident's call button was not working properly, resulting in staff not being notified and unable to assist the resident timely, and the facility was found to be in disrepair. Other allegations such as staff charging residents for services not rendered, not following care plans, and inappropriate communication were found unsubstantiated.

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 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 evidenced by the observed hot water temperature violation.

The inspection found that the hot water temperature in room 259 was 126.1 degrees F, exceeding the regulatory maximum of 120 degrees F, posing an immediate safety risk. A civil penalty of $250 was assessed for repeat violations.

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 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 the medication assistance allegation and unsubstantiated for allegations regarding refusal to accept resident back and denial of access to resident's records. The medication error involved staff marking medication as administered when it was not given, due to system and procedural issues.

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

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 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 complaint-related due to an elopement incident involving 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, posing a safety risk to residents.

The facility failed to prevent the elopement of resident R1 and did not report the incident within the required 24-hour timeframe. The resident was found without injury, and the facility updated the care plan and provided staff training.

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 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 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 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, and unsubstantiated for the allegation that staff did not abide by the admission agreement.

The allegation that staff did not ensure a resident had hot water was substantiated after interviews and facility tour revealed the hot water issue in one of the resident's bathrooms, which was resolved by replacing the boiler system. The allegation that staff did not abide by the admission agreement was unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated based on interviews, observations, and record reviews. The allegations included medication mismanagement, failure to notify residents and responsible parties, and untimely response to call buttons. The facility was found to have multiple medication errors, malfunctioning call buttons, and care plan discrepancies.

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

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 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 that the facility was in disrepair, staff were not following residents' care plans, incident reports were not sent as required, and medication was not administered as prescribed. Another complaint alleging the facility was not clean and sanitary, did not provide adequate care, had insufficient staff, and staff were administering controlled substances inappropriately was unsubstantiated due to lack of evidence.

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 administered as prescribed. The facility had issues with elevator, fireplace, washers, dryers, call buttons, and carpeting. Medication administration errors were identified. The prior Health and Wellness Director resigned due to discrepancies. Another complaint regarding cleanliness, adequate care, staffing, and controlled substance administration was found unsubstantiated.

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.

Two deficiencies were found: hot water temperature in a resident's room was measured at 133.6°F, exceeding the regulatory limit and posing an immediate safety risk; and none of the six staff files reviewed had current first aid training, posing a potential health and safety risk.

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 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 a fire exit was blocked. Other allegations about emergency disaster plans, evacuation chairs, and emergency drills were unsubstantiated.

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 to be unsubstantiated.

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 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.

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 inspection found 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 for some staff. An immediate $500 civil penalty was assessed for the fire clearance violation.

The complaint involved an allegation that a team member pushed a resident living in memory care. The allegation was substantiated based on interviews and reports.

The investigation found that on 2024-01-31, a staff member (S1) pushed a resident (R1) in memory care, constituting physical abuse. The resident had no injuries and was unable to recall the event. The staff member was terminated following the incident.

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.

The facility was found to have a census of 143 residents, exceeding its approved fire clearance capacity of 140, resulting in an immediate civil penalty of $500 for noncompliance with Title 22 California Code of Regulations.

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 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 evidence that the facility failed to provide a gluten and lactose free diet as prescribed by a resident's physician, posing a potential health and safety risk.

The investigation found that the facility did not provide gluten-free options as required by a resident's physician's order, substantiating the allegation that special dietary needs were not met. The Executive Director agreed to create a nutritional plan to comply with the doctor's orders.

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 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.

Complaint investigation was substantiated for medication administration delay. Other allegations including insufficient staff, staff yelling at residents, and inadequate care were unsubstantiated.

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

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

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 smoke detectors not being monitored was substantiated and addressed.

A deficiency was found where the licensee did not comply with fire safety regulations by not having smoke detectors monitored by a fire alarm company, posing a potential health and safety risk. The deficiency was cleared as the facility was cleared by the Fire Marshall on 11/10/22.