IVY PARK AT SAN TOMAS

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. This requirement is not met as evidenced by: Based on record review and interview, ED and HSD stated there were no documented reassessments or additional fall prevention measures after R1 fell on 10/17/2025 and 10/21/2025.

Official plan of correction

ED stated to submit a written plan of action stating understanding of the regulation cited and will submit a plan stating how the facility will ensure reappraisals are completed after a significant change to a resident. POC due by POC due date of 8/19/2026.

Deadline recorded: Aug 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

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: Based on interview, record review and observation the licensee did not comply with the section cited above wherein chemicals and hygiene products were observed in 9 out of 11 dementia resident rooms which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee states a plan to lock all chemicals/disinfectants. Licensee will submit a written plan and in-service staff training regarding the regulation cited to LPA Kabariti via email by POC due date.

Deadline recorded: Aug 12, 2026. 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. This was not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above when R1's room was observed soiled with feces on 9/2/2025, and was reported to Executive Director (ED) on 9/3/2025. ED stated she cleaned R1's room on 9/3/2025 when reported.

Official plan of correction

Licensee will submit a plan of action on how the facility will ensure resident's rooms are clean, safe, sanitary and in good repair at all times. Licensee to submit POC by POC due date 7/18/2026.

Deadline recorded: Jul 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(e)(3)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (3) Facility staff shall attempt to redirect a resident at risk for elopement who may be attempting to leave the facility without violating Section 87468.1, Personal Rights of Residents in All Facilities. This requirement was not met as evidenced by: Licensee did not ensure that facility staff redirected R1 as he/she left the facility, posing an immediate safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a Plan of Correction by 05/29/2026 stating how the licensee will conduct in-service training with staff on ensuring that staff redirect a resident at risk for elopement who may be attempting to leave the facility. Once training is complete, the licensee agrees to submit training records that include name of staff trained, training dates, training topics, and names and qualifications of trainers.

Deadline recorded: May 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This was not met as evidenced by: Based on interview and records reviews, on 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026 the ED stated she is unable to locate R1s documentation in storage.

Official plan of correction

ADM will submit a plan of correction to include how the facility will ensure residents records are retained for a minimum of 3 years following the termination of service to the resident. ED to submit POC by POC due date of 4/29/2026.

Deadline recorded: Apr 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above. LPA noted R1, R2 and R3 had medications that were not listed on the centrally stored medication record. LPA showed the discrepancy to the health services director Kyleigh Whitely but no documentation was provided to verify that the medications in question were included in each corresponding centrally stored medication record. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2026 Plan of Correction ADM stated her plan of correction will be to conduct a training, on how to centrally store medications. ADM stated she will send training documenation to LPA by POC due date. ADM stated she will send the plan of correction to LPA by POC due date, April 16, 2026

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464(f)(4) Basic services shall at a minimum include:(4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal... activities of daily living such as dressing, eating, bathing and assistance... this requirement was not met as evidenced by: Based on interview and photo, S1, S2 stated the facility was short staffed and the R1s laundry did not get washed. S1 stated R1 had to wear dirty clothing. RP provided photo R1 had soiled clothing on two seperate occasions 09/20/24, and 09/22/24. This posed a potential risk to the health and safety of residents in care.

Official plan of correction

Administrator stated she will provide a letter of understanding of regulation and has hired more staff. ADM will submit to LPA Yanez by POC due date 01/09/25 via email.

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

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465(g) Incidental Medical and Dental Care: (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including…apparent life-threatening medical crisis…This requirement is not met as evidenced by: Based on interview and record review, facility staff did not seek timely medical care for R1. On 08/05/24 R1s were recorded calling for help from 0400 to 0730 hrs. Staff were recorded coming into the R1s room at 0730 hrs. and 911 was called. S3 stated he/she was alerted

Official plan of correction

The ROS stated that the facility will conduct In-Service training with staff on wellness checks and will provide proof of training by POC due date 08/28/25 *cont'd: by staff when his/her shift started at approximately 0630 hrs. S4 stated R1 probably waited for four hours to get help because staff is probably attending to another resident emergency need. Which pose/poses an immediate health, safety and personal-rights risk to person in care

Deadline recorded: Aug 28, 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

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities…shall have all the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff… This requirement is not met as evidenced by: Based on interview staff did not provide care to R1 in a timely manner. On 08/05/24, R1 was recorded screaming for help from 0400 to 0730 hrs. S1 stated R1 waited for hours because “someone is not caring for R1.” S2 stated R1 was possibly waiting for hours to be helped

Official plan of correction

The ROS stated that the facillity will conduct In-Service training for staff to ensure residents rights are protected by POC due date 08/28/25 *cont'd :because there are 2 staff for all residents at the time of the incident. S3 stated he/she was alerted by staff when S3 arrived at 0630 hrs. that R1 had fallen in the bathroom. Which pose/poses an immediate health, safety and personal risk to person in care.

Deadline recorded: Aug 28, 2025. 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...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on investigation, R8 requires assistance with medication administration. Resident medication M1 was not administered on 7/8/2025. HSD stated " I don't know " regarding the discrepancy, which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee states the facility will conduct additional medication administration training by 7/15/2025. Licensee will submit the Plan of Correction (POC) by POC due date 7/9/2025, and submit completion of training to the Department.

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

Official classification

Type B

Official code

87465(h)(6)(A-F)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h)(6)(A-F) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement was not met as evidenced by Based on investigation, R7 to R10, LPAs noted that each resident has medications that were not listed on the Centrally Stored Medication log. HSD stated, " I don't know " regarding the discrepancies, which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee states the facility will conduct additional medication administration training by 7/15/2025. Licensee will submit the Plan of Correction (POC) by POC due date 7/9/2025, and submit completion of training to the Department

Deadline recorded: Jul 15, 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) 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 interview, record review and observation the licensee did not comply with the section cited above wherein chemicals and hygiene products were observed in 9 out of 11 dementia resident rooms which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee states a plan to lock all chemicals/disinfectants. Licensee will submit a written plan and in-service staff training regarding the regulation cited to LPA Kabariti via email by POC due date.

Deadline recorded: May 22, 2025. 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

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 facility was found to be deficient as evidenced by a review of the facility forms and documents revealing that a resident required more one on one care and supervision, with redirection, which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.

Official plan of correction

The facility designated representative stated that the personnel requirements and scheduling will be updated to show that the proper level of staffing is being maintained at all times. A statement of correction, along with a copy of the most current staffing schedule for 24 hours/7 days a week coverage, will be completed and submitted into CCL by the due date.

Deadline recorded: Dec 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited wherein 2 out of 2 side gates in the patio were observed locked using a combination lock which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee will remove the combination locks on the 2 side gates in the patio area and will replace the locks for a door alarm. Licensee will submit a picture of the 2 side gates and email communication regarding resolving the locks to the side gates to LPA Dolores via email by POC due date of 10/18/2024.

Deadline recorded: Oct 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(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 events specified in (A) through (D) below…. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not inform the Department of an incident within seven days of the occurrence of the event which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee will submit a statement of understanding of Title 22 Section 87211 to LPA Dolores via email by POC due date.

Deadline recorded: Aug 2, 2023. A deadline is not proof that correction was completed.