IVY PARK AT HAYWARD

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage...... ....and are not left unattended if outside the locked storage. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in unlocked scissors, Lysol, Neosporin and wound cleanser which pose an immediate risks to persons in care.

Official plan of correction

Executive Director (ED) had the items locked. In addition, ED to in-service the staff and submit copy of training topic with attendees signatures by 5/27/26. A $250.00 civil penaty is assessed.

Deadline recorded: May 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in 3 out of 7 apartments inspected with soiled/dirty carpet flooring which pose a potential personal rights risk to persons in care.

Official plan of correction

Executive Director stated he'll have the carpet flooring deep cleaned. Pictures to be submitted by 5/26/26.

Deadline recorded: Jun 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed as necessary........... -This requirement is not met as evidenced by: -Based on interviews and record review, the licensee did not comply with section above when R1 was able to leave the facility unnoticed which posed an immediate risk to person in care.

Official plan of correction

Corrected. The following were conducted: 1. Retraining of staff - copies obtained by LPA on this day, 5/13/26. 2. Wander guard installed on all entrance/exit doors. 3. Resident was moved to Memory Care Unit.

Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement......... -This requirement is not met as evidence by: -Based on observation and interviews, the licensee did not comply with the section above in front/exit door not having auditory signal and R1 was able to leave the facility unnoticed.

Official plan of correction

Auditory signal's battery was replaced while LPA was at the facility. AED stated they will start having the auditory signal checked everyday. In addition, AED to conduct in-service training and submit copy of training topic with attendees signatures by 12/03/25

Deadline recorded: Dec 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(1)(C)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals: (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition.... (1)..(C) Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations..... -This requirement is not met as evidence by: -Based on record review, the licensee did not comply with the section when R1's assessmrent was completed but not consistent with the current need which poses a potential satety risk to person in care.

Official plan of correction

AED to have the assessment corrected and submit copy by 12/16/25.

Deadline recorded: Dec 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having a razor in one of the apartments in memory care unit which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Executive Director (ED) removed the item. In addition, ED will in-service the staff and submit copy of training topic with attendees signatures by 10/31/25.

Official classification

Type A

Official code

87465(h)(1)(B)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in having Tylenol in the medication cabinet in the apartment of a resident who can not administer and store own medications which poses an immediate health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Excutive Director (ED) have the item removed. ED stated he'll in-service the staff. Proof to be submitted by 10/31/25.

Official classification

Type A

Official code

1568.03(b)

Regulation authority

CCR

What the official deficiency says

§1568.03 License requirements; levels of care; application of chapters; multiple licenses; enjoining violations: (b) A facility may accept or retain residents requiring varying levels of care. However, a facility shall not accept or retain residents who require a higher level of care than the facility is authorized to provide. …….. -This requirement is not met as evidenced by; -Based on interviews and record review, the licensee did not comply with the section above in retaining a resident who needed higher level of care which posed an immediate health, safety and/or personal rights risks to person in care.

Official plan of correction

R1 is no longer at the facility. Executive Director stated she'll do the following: 1. In-service the staff. 2. Ensure that resident needing higher level of care will be move-out accordingly.

Deadline recorded: Jun 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ...(2) The licensee shall provide assistance in meeting necessary medical and dental needs. ..... -This requirement is not met as evidenced by: -Based on record review and interview, the licensee did not comply with the section in not checking R1 blood pressure as ordered on particular dates which posed a potential health risk to resident in care.

Official plan of correction

Resident is no longer at the facility. AED to in-service the staff and submit proof by 1/30/25.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(6)

Regulation authority

CCR

What the official deficiency says

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers.... -This requirement is not met as evidenced by: -Based on interviews and record review, the licensee did not comply with the section above in R1 having overgrown toenails which posed a potential personal rights risk to person in care.

Official plan of correction

Resident is no longer at the facility. AED to in-service the staff and submit proof by 1/30/25.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in the following which poses an immediate s afety or personal rights risks to persons in care: razor, hair developer, perming agent, waving lotion, anti fungal wash and screw driver in unlocked drawers in unlocked salon; cleaning supplies in unlocked housekeeping room on the 5th floor. This is a repeat violation within 12-month period. A citation was issued on 10/04/23.

Official plan of correction

POC Due Date: 09/27/2024 Plan of Correction AED locked the salon and the housekeeping room. In addition, an in-service will be conducted and proof to be submitted by 9/27/24.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in R3 having medications in the room and Peritoneal cleanser in another resident's room which poses an immediate health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2024 Plan of Correction Peritoneal cleanser was removed. AED stated she'll have the medications locked. In addition, an in-service to be conducted and proof to be submitted by 9/27/24.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in stained/soiled carpet flooring which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 10/10/2024 Plan of Correction AED stated she'll have the carpet cleaned. Pictures to be submitted by 10/10/24.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S5 not having the require total initial hours of medication training which poses a potential health and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2024 Plan of Correction Staff to complete the required medication training and submit proof by 10/10/24.

Official classification

Type B

Official code

1569.625

Regulation authority

CCR

What the official deficiency says

§1569.625 Staff training; legislative findings; contents (b)(1)…training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required..... before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment….(2) ... training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.... This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in S1, S3 and S5 not completing the required numbers of hours of training which poses a potential health, safety or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 10/10/2024 Plan of Correction AED to have the staff complete the training and submit proof by 10/10/24.

Official classification

Type B

Official code

87608(a)(b)

Regulation authority

CCR

What the official deficiency says

87608 Postural Support (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and records review, the licensee did not comply with the section cited above in R2 and R4 not having doctor’s order for the postural support which pose a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 10/10/2024 Plan of Correction Doctor's orders to be obtained and copies to be submitted by 10/10/24.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental,..... .....and social condition. -This requirement is not met as evidenced by: - Based on records review and interview, the licensee did not comply with the section above for not doing a re-appraisal or updating Care Plan after R1 had multiple falls in few months.

Official plan of correction

R1 is no longer at the facility. Executive Director stated she'll have all the files double checked and ensure records are updated. Self-certification to be submitted by 1/05/23.

Deadline recorded: Jan 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the event.(D)Any incident which threatens the welfare, safety or health of any resident,... -This requirement is not met as evidenced by: - Based on records review and interview, the licensee did not comply with the section above for not submitting incident report for R2 which poses a potential health, safety and/or personal rights risks to person in care,

Official plan of correction

R2 is no longer at the facility. Executive Director stated an in-service training for the Wellness Department will be conducted to ensure enforcement of Reporting Requirements. Copy of in-service to be submitted by 1/05/23.

Deadline recorded: Jan 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for blade and scissors in the drawer without lock in unlocked salon, and professional strength glue, paint spray, fabric and vinyl adhesive spray in cabinets without lock in unlocked art room. These pose an immediate health and/or safety risks to persons in care. This is a repeat violation within 12 months period. First citation was issued on 8/03/23. A $250.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 10/05/2023 Plan of Correction ED locked the rooms. In addition, ED to conduct in-service training and submit copy of training topic with attendees signatures by 10/05/23.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above for staff (S2) not having first aid training and/or certificate on file which poses a potential safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction ED to have the staff trained and submit proof by 10/18/23.

Official classification

Type B

Official code

1569.69

Regulation authority

HSC

What the official deficiency says

§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above for staff (S5) not having the required 8 hours of medication training for 2022 which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction ED to have the staff complete the required training and submit proof by 10/18/23,

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for having cabinets, drawers, storage without lock and/or unlocked where cleaning, art and salon supplies and scissors are kept which pose immediate safety risks to persons in care.

Official plan of correction

Staff locked the rooms. In addition, an in-service training to be conducted and copy of training topic with attendees signatures to submitted by 8/03/23.

Deadline recorded: Aug 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year..... -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for not having medical assessment and/or LIC602A for R1 which poses potential health and/or safety risks to person in care.

Official plan of correction

Administrator to obtain medical assessment, and submit copy by 8/17/23.

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria... -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for R1 without pre-admission appraisal which poses oses potential health and/or safety risks to person in care.

Official plan of correction

Administrator to have the document completed and submit copy. In addition, administrator to ensure that in the future, a pre-admission appraisal is completed before admission. Proof to be submitted by 8/17/23,

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(c)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. -This requirement is not met as evidenced by -Based on records review, the licensee did not comply with the section above for R2's medical assessment indicating R2 has dementia but can administer medications which is not consistent with doctor's note indicating R2 can not determine need for medications,

Official plan of correction

Administrator to have the documents updated, and submit copies by 8/17/23.

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

87618 Oxygen Administration - Gas and Liquid (b).., the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements:(B) " No Smoking-Oxygen in Use " signs shall be posted in the appropriate areas. -Based on observation, the licensee did not comply with the section above for not having the sign posted in appropriate place which poses a potential risk to persons in care,

Official plan of correction

Administrator to have a sign posted,and submit picture by 8/17/23.

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering...... -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for R1 who has dementia was able to leave the facility unnoticed which posed immediate safety risk to person in care.

Official plan of correction

AED stated R1's care plan has been updated after the incident. In addition, AED to in-service the staff and submit copy with attendees signatures by 01/20/2023

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. -This requirement is not met as evidenced by -Based on observation, the llicensee did not comply with the section above.for the auditory device on the front door not working which poses immediate safety risks to persons in care.

Official plan of correction

AED had the Maintenance Director checked device immediately. In addition, AED to in-service the staff and submit copy with attendees signatures by 01/20/2023

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above. Facility has residents with dementia and the room with construction tools/equipments and chemicals was unlocked which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2022 Plan of Correction AED locked the room immediately. In addition, AED to conduct in -service training and submit proof by 10/11/2022.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87555 General Food Service Requirements: (a)....... All food shall be selected, stored, prepared and served in a safe and healthful manner. -This requirement is not met as evidenced by; -Based on inspection, the licensee did not comply with the section above. LPA observed 3 cans of expired prunes which pose immediate health risks to persons in care.

Deadline recorded: Oct 21, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above. LPA observed the following which pose immediate health and safety risks to persons in care: frayed carper flooring in resident's room; bathroom doors in one of resident's bedroom; insect killers, uneven pavement and pieces of metal in the patio

Official plan of correction

Associate Executive Director (AED) had the insect killers locked and the bathroom doors removed from the bedroom immediately. AED to have following done: 1. Have the carpet flooring fixed/repaired. 2. Fix the uneven pavement. 3. Remove the pieces of metal from the patio and/or place a yellow construction tape around the area. 4. In-service the staff. Pictures and copy of in-service training to be submitted by 9/07/2021.

Deadline recorded: Sep 7, 2021. A deadline is not proof that correction was completed.