Inspection Reports for Ivy Park at Seven Oaks

The visit was an unannounced complaint investigation triggered by allegations including a resident being sexually assaulted by another resident and staff not assisting residents timely due to short staffing.

The investigation included interviews, facility tour, and record review. Observations showed locked rooms for nonambulatory and bedridden female residents in memory care, timely staff response to call pendants, and no evidence supporting the allegations. The complaint was found to be unsubstantiated.

The complaint was unsubstantiated based on the preponderance of evidence standard after investigation.

An unannounced complaint investigation was conducted in response to a complaint received on 2025-04-25 alleging that staff yelled at a resident.

The investigation included interviews, facility tour, and record review. The allegation that staff yelled at a resident was found to be unsubstantiated based on the preponderance of evidence standard.

The complaint alleged that staff yelled at a resident. The allegation was found to be unsubstantiated.

Unannounced complaint investigation visit conducted in response to allegations received on 2024-12-13 regarding neglect and inadequate care of residents.

The investigation found insufficient evidence to substantiate the allegations of staff neglect, failure to meet diapering needs, and delayed medical attention. The allegations were determined to be unsubstantiated after interviews, record reviews, and facility tour.

Allegations included staff neglect resulting in pressure injuries, failure to ensure diapering needs were met, and not seeking timely medical attention. The complaint was found to be unsubstantiated.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at the assisted living and memory care facility.

The facility was generally clean, in good repair, and equipped with necessary safety features. However, several deficiencies were cited including unsafe storage of hazardous items accessible to residents, medication administration errors, hot water temperatures exceeding regulatory limits, and improper freezer temperature maintenance.

The visit was conducted as a case management health and safety visit following a concern about staff providing care to a resident. The purpose was to review records, conduct interviews, and tour the facility.

The Licensing Program Analyst conducted the visit, reviewed records, interviewed staff, and toured the facility. The information will be reviewed and a follow-up case management visit will be conducted if necessary.

The inspection was an unannounced case management visit regarding the immediate exclusion of a staff member (Staff 1).

The excluded staff member was confirmed not to be associated with or employed by the facility. No deficiencies were observed during the inspection.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2024-10-24 alleging that staff did not follow a resident's Physician Orders for Life-Sustaining Treatment (POLST).

The investigation found that the facility followed the resident's signed POLST and attempted CPR unless otherwise directed by a doctor. The allegation was determined to be unfounded and the complaint was dismissed.

The complaint alleged that staff did not follow the resident's Physician Orders for Life-Sustaining Treatment (POLST). The investigation concluded the allegation was unfounded, meaning it was false, could not have happened, or was without reasonable basis.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident had unexplained injuries while in care.

The investigation included interviews, record reviews, and a facility tour. It was determined that the resident is ambulatory with a history of falls, and there was insufficient evidence to prove or disprove the allegation. The complaint was found to be unsubstantiated.

The complaint alleged that a resident had unexplained injuries while in care. The allegation was found to be unsubstantiated after investigation.

The visit was an unannounced Plan of Correction (POC) inspection conducted to verify correction of deficiencies cited on 01/23/2024.

No deficiencies were observed during the visit. The Plan of Correction was found to be cleared as the Licensing Program Analyst toured rooms and did not observe any issues with cleaning chemicals, knives, or medications.

The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations at the facility.

The facility was generally clean, well-maintained, and properly equipped with safety features. However, deficiencies were cited related to unsecured medications and unlocked sharps and chemicals accessible to residents, posing immediate health and safety risks.

A virtual office meeting was conducted to discuss recently identified issues and concerns associated with the operation of the facility.

The meeting addressed concerns regarding the resident's admission agreement and refund, with the administrator informed that a refund is due by 11/27/2023.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-10-24 alleging illegal eviction at the facility.

The investigation included interviews and record reviews, finding that the resident had a doctor's order for hospitalization and an alternative placement was arranged. The allegation of illegal eviction was found to be unsubstantiated based on the preponderance of evidence.

The complaint alleging illegal eviction was investigated and found to be unsubstantiated.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-10-24 alleging that staff failed to prevent residents from engaging in a physical altercation which resulted in injuries.

The investigation included interviews and record reviews. Staff were present and intervened to stop the physical altercation between residents. The allegation was found to be unsubstantiated based on the preponderance of evidence.

The complaint alleged staff failed to prevent residents from engaging in a physical altercation resulting in injuries. The allegation was found to be unsubstantiated.

Unannounced visit/investigation of a complaint received on 09/28/2023 regarding an allegation of illegal eviction.

The investigation included interviews and record reviews which confirmed that the resident's son requested the facility to deny the resident's return from the hospital. The allegation was found to be unsubstantiated based on the preponderance of evidence standard.

The complaint allegation was illegal eviction. The investigation found the allegation to be unsubstantiated.

A virtual office meeting was conducted to discuss recently identified issues and concerns associated with the operation of the facility.

The meeting addressed concerns regarding the resident's admission agreement and required the administrator to submit additional documents related to care services changes, specifically Companion Care charges.

The visit was a case management follow-up to address information received regarding the facility's failure to provide a refund to resident 1 for community fee and refund fee.

Based on records reviewed and interviews conducted, resident 1 resided at the facility for over 90 days after the community fee refund contract prorated basis and no refund was issued; the resident has a remaining balance for companion care services. No deficiencies were issued.

An unannounced complaint investigation was conducted in response to a complaint received on 07/19/2023 regarding staff refusing to allow a resident to return to the facility after a hospital stay.

The complaint was substantiated based on the investigation conducted on 07/24/2023. The allegation was addressed during a case management visit on 07/18/2023 and cited under California Code of Regulations, Title 22, Division 6, Chapter 6.

The complaint was substantiated as staff refused to allow a resident to return to the facility after a hospital stay. This was cited under California Code of Regulations, Title 22, Division 6, Chapter 6 during a case management visit on 07/18/2023.

The visit was an unannounced case management deficiency inspection to follow up on an incident that occurred on 07/20/2023 involving the administration of the wrong medication to a resident.

A deficiency was cited for failure to assist residents with self-administered medications as needed, evidenced by a staff member administering the wrong medication to a resident, posing immediate health and safety risks.

The visit was conducted to address an incident where resident R1 went AWOL from the facility on 07/10/2023.

A deficiency was cited because staff did not provide adequate care and supervision when R1 left the facility unsupervised, posing an immediate health and safety risk.

The visit was complaint-related due to the incident of resident R1 going AWOL. The deficiency was substantiated and cited.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-02-17 regarding the facility not following a resident's admission agreement.

The investigation found that the admission agreement was not updated to reflect the hours of one-on-one care the resident needed, and the charges for this care were not agreed to or signed by the responsible party. There was no updated physician report or assessment supporting the need for 24-hour one-on-one care. The allegation was substantiated.

The complaint was substantiated based on the preponderance of evidence standard. The allegation was that the facility did not follow the resident's admission agreement regarding one-on-one care charges.

An unannounced complaint investigation was conducted following a complaint received on 2023-02-28 regarding the facility's failure to notify residents that pendant alarms were not working.

The investigation found the allegation to be unsubstantiated as the facility notified residents and responsible parties within 24 hours of the alarm system failure and took proper measures to ensure resident safety.

The complaint alleged the facility failed to notify residents that pendant alarms were not working. The allegation was found unsubstantiated based on observations, records, and interviews.

The visit was a follow-up pre-licensing inspection (Component III) to verify that the applicant met all pre-licensing requirements for the facility.

The Licensing Program Analyst observed that medications and sharps were removed from residents' rooms and inaccessible to residents, and cleaning chemicals were stored and locked. The applicant met all pre-licensing requirements and the report will be submitted for final review prior to license issuance.

The visit was an announced pre-licensing / Component III inspection conducted to evaluate the facility prior to licensing.

The inspection included a tour of the facility and review of resident and staff records. Several compliance issues were identified including the need for non-skid mats in showers and proper storage of medications, cleaning chemicals, and sharps to keep them inaccessible to residents.

The visit was an office evaluation related to a Change in Ownership (CHOW) application for a Residential Care Facility for the Elderly (RCFE). The Administrator participated in a Component II interview to verify understanding of licensing laws and facility operation.

The Component II completion was successful. The Administrator demonstrated understanding of community care facility licensing laws, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.