IVY PARK AT SAN RAMON

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 hot water measuring at 129.2 degrees F in room 269 which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction By POC Facility agrees to monitor and adjust the boilers to ensure that the water temperature does not exceed 120 degrees F and notify CCLD

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 accesable gardening sheers unlocked in activities room under sink, chemicals unlocked under sink/ butane, room 196 hot tools, room 297 unlocked cleaning supplies/chemical hot tools which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction By POC facility agrees to identify all accesiable dangerous items and secure and notify CCLD

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. 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 Room 293 Incontinence not properly disposed creating an Odor which posed a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Items disposed of POC clear

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(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 to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in not enough staffing memory care; observed residents left unattended in activities room (2 caregivers on the floor for 30 residents. 1 upstairs 1 down), and staff were not aware (compitent) that MC has emergency call buttons which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction By POC facility agrees to hire more staff and train them and notify CCLD

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based onrecord review, the licensee did not comply with the section cited above in 4 out of 5 residents records review not having an updated annual appraisal which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction By POC Facility agrees to review all residents appraisals and ensure they are up to date and notify CCLD

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair... 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 downstairs common bathroom emergency call button not notifying caregivers pagers which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction By POC facility agrees to verify all call buttons and pagers are opperational and notify CCLD

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(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 to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidence by: Based on interviews the licensee did not comply with the section cited above by not having adequete staffing in memory care which allowed R2 to wander into R1's room unbeknownst to staff which posed a potential personal rights violation to residents in care

Official plan of correction

Facility has hired additional staff and trained them POC clear.

Deadline recorded: Mar 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(16)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(16)To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency. This requirement was not met as evidence by: Based on record review and interview R1 did not receive a written 30 day notice of room change prior to the change which poses a potential personal rights risk to resident in care

Official plan of correction

Facility has implemented a new system of documenting and notifing residents and their responsible parties of room changes and provided the new form to CCLD. POC clear

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

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

HSC

What the official deficiency says

87465(h)(2) Incidental Medical and Dental Care “Once ordered by the physician, medications shall be given according to the physician’s directions.” Residents’ medications must be safeguarded to ensure they are administered only to the prescribed individual and strictly in accordance with the physician’s directions. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not ensure the safeguarding of residents’ medications. Medications were found unsecured and accessible, creating a risk that residents may receive medications not prescribed to them or that doses may not be administered as directed. This poses an immediate health and safety risk to residents in care.

Official plan of correction

The licensee shall immediately implement corrective measures to ensure all medications are stored securely and accessible only to trained staff. The licensee shall retrain staff on medication safeguarding policies and procedures. Documentation of staff training and photographs of corrected storage practices shall be submitted to Community Care Licensing by 10/10/2025.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

HSC

What the official deficiency says

87468.2(a)(4) – Personal Rights of Residents in All Residential Care Facilities for the Elderly “To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” Residents shall be provided with safe, healthful, and comfortable accommodations, which includes the proper administration of prescribed medications to ensure resident health and safety. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure that medications were administered as prescribed. Documentation confirmed that staff failed to follow physician’s orders regarding medication administration, resulting in missed and/or delayed doses. This posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee shall provide immediate retraining for all staff responsible for medication administration, with emphasis on adherence to physician’s orders and proper medication administration procedures. Proof of completed staff training, including attendance records and training materials, shall be submitted to Community Care Licensing by 10/10/2025.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair... This requirment was not met as evidence by: Based on observations and interview the facility did not comply with the following by R1's call button being in disrepair which poses a potential safety and personal rights violation to residents in care

Official plan of correction

By POC facility agrees to inspect and replace residents personal call buttons as neccessary and notify CCLD

Deadline recorded: Sep 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above inhot water temprature measuring at 126.1 which poses an immediate safety risk to persons in care.

Official plan of correction

By POC facility agrees to adjust the water to regulations and notify CCLD.

Deadline recorded: Aug 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ... This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above staff neglecting to ensure that the memory care door fully closed behind them which led to R1s elopement which posed an immediate safety risk to residents in care

Official plan of correction

Facility updated R1's care plan and provided training to staff POC clear.

Deadline recorded: Jul 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(6)(B)

Regulation authority

CCR

What the official deficiency says

(6) For each incident of elopement..(B)The licensing agency...no later than the next working day ... This requirment is not met as evidence by: Based on interviews the facility did not meet the requirement above by not reporting the elopement of R1 within 24hrs to CCLD which poses a potential safety risk to residents in care

Official plan of correction

By POC facility agrees to review the regulations and provide an in service to staff and notify CCLD.

Deadline recorded: Jul 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows:(2)Faucets...Hot water temperatur ... not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).... This requirement was not met as evidence by: Based on interview the facility did not comply with the following by not having hot water in 1 of 2 of R1's showers which poses an immediate safety and personal rights violation to residents in care.

Official plan of correction

Facility has obtained a new boiler system and the hot water issue has been resolved.

Deadline recorded: May 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish ... reports...but not limited to, the following: this requirement was not met as evidence by: Based on interview the facility did not comply with the following by not reporting incidents as required which poses a potential safety and personal rights violation to residents in care

Official plan of correction

ED states that previous HWD has resigned and new staff has been adequately trained on procedure

Deadline recorded: May 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair... Based on observations and interview the facility did not comply with the following by the call buttons being in disrepair which poses a potential safety and personal rights violation to residents in care

Official plan of correction

By POC ED agrees to have an order for replacment of call buttons that are in disrepair along with their notification counterparts. LPA will return to inspect the call buttons when relaced

Deadline recorded: Jun 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

(a) A plan ...by compliance with the following: this requirement was not met as evidence by: Based on record review the facility did not comply with the following by having an inaccurate MAR which put into question the validity of the entries which poses a potential safety and personal rights violation to residents in care.

Official plan of correction

System has been updated and staff was retrained on how to adequetly document medications.

Deadline recorded: May 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair... Based on observations and interview the facility did not comply with the following by the elevator, fireplace, and other utilities being in disrepair which poses a potential safety and personal rights violation to residents in care.

Official plan of correction

Elavator, fireplace, and washing utilities have been repaired or replaced. ED is currently developing a solution for replacment of call buttons that are in disrepair along with their notification counterparts. By POC ED agrees to have an order for all carpets to be replaced in assisted living and send a copy of the work order to ccld. LPA will return to inspect when new carpets are installed.

Deadline recorded: May 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish ... reports...but not limited to, the following: this requirement was not met as evidence by: Based on interview the facility did not comply with the following by not reporting incidents as required which poses a potential safety and personal rights violation to residents in care

Official plan of correction

ED states that previous HWD has resigned and new staff has been adequately trained on procedure

Deadline recorded: May 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

(a) A plan ...by compliance with the following: this requirement was not met as evidence by: Based on record review the facility did not comply with the following by having an inaccurate MAR which put into question the validity of the entries which poses a potential safety and personal rights violation to residents in care.

Official plan of correction

By POC facility agrees to review the regulation and notify CCLD

Deadline recorded: Jul 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(f)

Regulation authority

CCR

What the official deficiency says

(f) The licensee shall .., communicate ... any significant change ...Documentation...shall be added to the resident’s record. this requirement was not met as evidence by: Based on record review and interview the facility did not comply with the following by previous HWD updating residents care plan and not notifying the appropriate parties and not providing the care specified which poses a potential personal rights violation to residents in care.

Official plan of correction

HWD has since resigned and new staff has been trained appropriately.

Deadline recorded: May 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above inhot water temprature measuring at 133.6 which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction By POC facility agrees to adjust the water to regulations and notify CCLD.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 in 6 out of 6 staff files reviewed not having first aid which posesa potential health and safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2025 Plan of Correction By POC facility agrees to have all staff update their first aid and notify CCLD

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement is not met as evidence by: Based on observation the fire exit in stairwell behind door six was blocked by an industrial shampoo machine which posed an immediate health and safety risk to residents in care.

Official plan of correction

Staff removed and stored shampooer in a safe location not blocking a fire exit.

Deadline recorded: Jun 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(10)

Regulation authority

HSC

What the official deficiency says

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and reports S1 pushed R1 thereby physically abusing them.

Official plan of correction

Staff was terminated.

Deadline recorded: Mar 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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 by having R1 in room 194 which is not an approved bedridden room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2024 Plan of Correction By POC date Executive Director agrees to either have the resident evaluated for hospice or start the process of moving residents room to an approved bedridden room and notify CCLD

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 2 out of 5 staff records reviewed not having health screens and TB results which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2024 Plan of Correction By POC date Executive director agrees to review all staff files to ensure they have the required documentation and update the files if they do not and notify CCLD

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 in 2 out of 5 staff files reviewed not having valid first aid training or card on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2024 Plan of Correction By POC date Executive Director agrees to have required staff first aid certified and update their files in to be in compliance with regulation and notify CCLD.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202(a) Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... Based on interview, the licensee did not comply with the fire clearance. The facility has an approved fire clearance for a capacity of 140, however the facilities current census is 143 which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care

Official plan of correction

Administrator will submit a capacity increase to CCL by POC date An immediate $500 civil penalty is being assessed today

Deadline recorded: Oct 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing R1 with diet prescribed by physician which poses a potential health and safety risk to the persons in care.

Official plan of correction

Executive Director has agreed to work with R1 and create a nutritional plan to follow doctor's order for gluten and lactose free diet. Executive Director will submit plan to CCLD by POC date.

Deadline recorded: Aug 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident…(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's order for R6's medication which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator has agreed to retrain medication technician staff on medication administration. Administrator will submit staff sign-in sheet and training materials to CCLD by POC date.

Deadline recorded: May 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Based on record review and interview, Licensee did not comply with the regulation cited above by not having smoke detectors monitored by fire alarm company which poses a potential health and safety risk to residents in care.

Official plan of correction

DEFICIENCY CLEARED. LPA obtained a copy of Fire & Life Inspection Report stating violation has been cleared by Fire Marshall on 11/10/22

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.