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 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 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

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.