Inspection Reports for The Ivy at Golden Gate

An unannounced case management visit was conducted to follow up on an incident report submitted on 2025-10-03 regarding a resident who eloped from the facility without supervision.

The facility failed to provide adequate care and supervision to a resident diagnosed with Alzheimer's dementia, who was able to leave the facility unassisted. This deficiency was cited under California Code of Regulations, Title 22.

The visit was triggered by a complaint incident report regarding Resident R1 eloping from the facility without assistance. The complaint was substantiated as the facility failed to provide adequate supervision.

An unannounced annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements.

The facility was found to be clean, well-maintained, and compliant with all regulations. No deficiencies were cited during the inspection.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-03-14 alleging that a client's care needs were not being met by staff.

The investigation found that the client's wounds were pre-existing and being appropriately treated by the facility along with outside medical care. Interviews and record reviews indicated the facility was providing appropriate care and meeting resident needs. The complaint allegation was determined to be unsubstantiated with no deficiencies cited.

Complaint alleged that client R1's care needs were not met by staff, with observations of poor condition. The allegation was unsubstantiated after investigation, meaning there was insufficient evidence to prove the alleged violation occurred.

The visit was an unannounced complaint investigation triggered by allegations received on 2025-02-12 regarding medication distribution, resident record maintenance, and communication with a resident's responsible party.

The investigation found no evidence to substantiate the allegations. Medication administration records and resident records were maintained properly, and documented communication with the responsible party was confirmed. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not distribute resident's medication as prescribed, did not maintain current resident records, and failed to communicate with the responsible party regarding resident's care service. These allegations were found unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-02-21 regarding medication administration and timely prescription refills at the facility.

The investigation found no corroborating evidence to support the allegations that staff did not ensure medication was dispensed as prescribed or that prescriptions were not refilled timely. Staff interviews and record reviews indicated medication was administered appropriately, and delays in physician orders were documented. The allegations were determined to be unsubstantiated.

The complaint alleged staff failed to dispense medication as prescribed and did not refill prescriptions timely. The investigation included interviews with staff and review of resident medication and hospice records. The findings were unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit conducted to address allegations that the facility did not issue a refund to residents R1 and R2.

The investigation found that residents R1 and R2 had signed an admissions agreement effective 7/31/2024 and had voluntarily refused to move their belongings into the facility. The facility provided the appropriate pro-rated community fees refund. The complaint was determined to be unfounded with no deficiencies cited.

Complaint alleged the facility did not issue a refund to residents R1 and R2. The allegation was found to be unfounded after review of admissions agreements, interviews, and documentation.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility did not issue a refund to a resident.

The complaint was substantiated as the facility had delayed refunding the monthly fees to the resident beyond the agreed 21-day period after the resident vacated and removed personal property. The level of care fees were refunded timely, but the monthly fees were not fully refunded until over two months later, violating the admissions agreement.

The complaint alleged that the facility did not issue a refund to resident R1. The allegation was substantiated based on evidence that the refund of monthly fees was delayed beyond the agreed timeframe, violating the admissions agreement and state regulations.

The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2024-01-29 regarding multiple allegations about facility care and services.

The investigation found no preponderance of evidence to substantiate the allegations, including issues related to accommodations, meal service during isolation, medication administration, staff conduct, and COVID-19 room cleaning. The allegations were therefore unsubstantiated.

The complaint included allegations that facility staff failed to provide safe, healthful, and comfortable accommodations; failed to provide tray service when a resident was ill; failed to provide medication according to physician's directions; failed to accord dignity in personal relationships; and did not clean and disinfect a COVID-positive resident's room. The investigation concluded these allegations were unsubstantiated.

An unannounced Annual Required – 1 year inspection was conducted to evaluate the facility's compliance with regulatory standards.

The facility was found to be clean, well-maintained, and compliant with safety and care regulations. No deficiencies were cited during the visit, and all reviewed resident and staff files, as well as medication records, were in order.

An unannounced visit was conducted by Licensing Program Analyst John Calandra to deliver an immediate exclusion letter to exclude a private companion who previously worked in the facility and is not allowed to work there.

The immediate exclusion letter was delivered and reviewed with the Executive Director, Katherine Raukhman, who was advised that the excluded private companion is not allowed to work in the facility. The report was reviewed, discussed, and a copy was provided.

An unannounced Pre-Licensing visit was conducted to evaluate the facility for licensing approval.

The facility was found to be clean, in good repair, and in compliance with Title 22 regulations. No safety hazards were observed, and required records and postings were maintained.

The visit was an office type evaluation involving a telephone interview with the administrator as part of a Change of Ownership (CHOW) application process.

The applicant/administrator demonstrated understanding of community care facility licensing laws, including facility operation, admission policies, staffing requirements, restrictive health conditions, and general provisions. Identification was verified and required documentation was obtained.