Ivy Park at San Ramon

PG 2 On the allegation, lack of supervision, resulting in resident being sexually abused at the facility LPA conducted interviews, reviewed R1 and R2’s care plan, R1 and R2’s physicians report, and care notes. LPA observed that R1 and R2 were both memory care residents with a diagnosis of dementia. On 8/13/2025 it is alleged that R2 entered R1’s room and sexually assaulted them. LPA interviewed S1 who is the lead for S3 who stated that on 8/13/2025 S3 had led R2 to Dining for breakfast. Approximately 30 minutes later, S3 noticed that R2 was not at dining. S1 states that other facility staff and S3 were still getting residents to dining for breakfast at this time. R2 was discovered in R1’s room during this time. S1 states that they were told that it appeared that R1 and R2 may have engaged in sexual activities. LPA conducted interviews with S2 S4 and S5. All staff stated that they had heard about the interaction between R1 and R2 however, residents have a personal right to engage in sexual activity, unless there is a court appointed conservator. LPA found that R1 and R2 are not conserved. LPA attempted to interview R1 but was unable to due to their dementia diagnosis. R2 was also unavailable to interview. LPA made attempts to contact S3 but was unable to interview S3 as they are not permanent staff. LPA was unable to determine if the interaction between R1 and R2 was consensual therefore, the allegation of lack of supervision resulting in resident being sexually abused at the facility is unsubstantiated. Report Continues on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 PG. 3 On the allegation facility not following reporting requirements LPA reviewed records and unusual incident reports. LPA observed that the facility reported the interaction between R1 and R2 on 8/18/2025 which is within title 22 guidelines of reporting requirements. LPA observed that the incident happened on 8/13/2025 was reported to police, responsible parties, and to licensing therefore the allegation facility not following reporting requirements is unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited. Exit interview conducted and a copy of this report provided.

PG. 2 On the allegation “Facility staff neglected resident contributing to questionable death” the following was found. R1 was admitted to the facility on 4/29/2024. On 8/8/24, the facility staff took over medication administration for R1 per their responsible parties request. On 8/27/24, R1 was having chest pains and was sent to San Ramon Valley Regional Hospital. R1 was diagnosed with low potassium. R1 was treated and sent back to the facility the same day with no new orders. On 9/11/24, R1 was having trouble breathing and was sent to the hospital on 9/12/24. R1 was diagnosed with low potassium levels and bloody fluid coming from the lungs. R1 was discharged from the hospital on 9/26/24. R1 did not return to the facility and was transferred to home health care at their responsible parties home. On 9/28/24, R1 was having shortness of breath and weakness and was transported back to the hospital while in their families care. On 10/4/24, R1 was transferred to a skilled nursing facility (SNF). On 11 /7/24, R1 was having trouble breathing while at the SNF. R1’s lungs were drained and appeared to be doing better. On 11/12/24, R1 tested positive for MRSA and went back to the hospital. R1 was placed on hospice and passed at the hospital on 11/17/24. It was alleged that Ivy Park San Ramon missed R1’s potassium medication however it could not be confirmed after a review of the Medication Administration Record (MAR ) For 7/01/2024-9/26/2024. R1 was also taking medication for congestive heart failure, medications were classified as a diuretic (water pill), a common side effect is a drop in potassium level (hypokalemia). According to Mayo clinic hypokalemia is, “Low potassium a condition in which the potassium level in your bloodstream is lower than is typical. The medical term for this condition is hypokalemia”. Report continues on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 PG. 3 R1 also had a complex past medical history with comorbidities and was taking multiple medications as prescribed. A copy of R1’s death certificate revealed R1 passed away on 11/17/2024 at JOHN MUIR MEDICAL CENTER-WALNUT CREEK and the cause of death was listed as chronic respiratory failure and heart failure; the etiology is unknown. A causal connection could not be established between the care at the facility and R1s expiration. Therefore, the allegation “Facility staff neglected resident contributing to questionable death” is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited. Exit interview conducted and a copy of this report provided.

On 3/6/26 at 1:00PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Gilbert Castro and explained the purpose of the visit. The facility’s fire clearance was approved for 162 residents of which 119 may be non-ambulatory and 4 bedridden. LPA toured the facility with ED including but not limited to residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 129.2, 111.9, 111.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid flooring/strips. Freezer measured at 0 degrees and refrigerator measured at 40 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Fire extinguisher was last serviced on 5/30/2025. No deficiencies cited at this time. LPA will return at a later date to continue annual inspection, records review, and cite for deficiencies observed. Exit interview conducted and a copy of this report provided.

On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R1 MAR where medication was marked as administered however R1 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight. LPA already cited for 87465(a) on complaint: 15-AS-20241203085000 The following deficiencies were observed (see LIC 809D on complaint 15-AS-20241203085000) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted and a copy of this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During the course of the investigation LPA interviewed W1 and reviewed correspondences with R1's responsible party. LPA was unable to identify where the facility refused to accept R1 back into care after R1 was sent out to the hospital. LPA also observed that R1's responsible party requested R1's the medication list on 8/28/2024 at 08:21:13 PM PDT via email and that the facility's Health and wellness director (HWD) at the time provided the medication list on 8/28/2024 at 9:30 PM. R1's power of attorney also requested R1's full record and provided proof of POA on 1/22/2025. The initial request was made on or around 1/14/2025 however the proof of POA documents still needed to be submitted based on the correspondences provided. At the time of the request R1 was not a resident of the facility and had passed away. R1 left Ivy park in September of 2024 and passed away a couple of moths later at an unrelated facility. The facility provided the requested records to R1's POA on 1/22/2025 via email as requested by the POA. Therefore the allegations of "Staff refused to accept resident back to the facility" and "Staff did not allow resident's representative to access resident's records" are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/1/25 at 10:00 AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of an self-reported incident report received 7/24/2025. LPA met with Business Office Director Thaleana Jones and explained the purpose of the visit. It was reported that R1 alleged that R2 hurt them on 7/23/2025. Facility also self-submitted the required SOC341 report of abuse. LPA reviewed R1 physician report and observed that R1 has a diagnosis dementia. R1 and R2 share a room. It was observed that R2 is non-ambulatory and would not have been able to commit what was alleged, there also was no evidence of the allegations. The police and responsible party were also notified. R1 and R2 continue to live together by choice. R1 is being monitored for this change in condition and their needs and services plan has also been updated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 7/1/25 at 2:40 PM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of delivering an amended complaint. LPA met with Executive Director Orisha Morgan and explained the purpose of the visit. LPA delivered an amended report for complaint #15-AS-20241203085000. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 6/4/25 at 5:00 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Business Director Thaleana Jones and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. A sample of the hot water temperature was measured at 119.6, 119.6, and 114.9 degrees F. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Refrigerator temperature was observed at 40 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/30/25. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On the allegation Staff do not ensure a resident has hot water LPA found the following: When LPA spoke with the ED they states that they were aware that there was an issue with the hot water especially in R1's room. ED states that the issue took a few months to resolve because they were trying to locate the issue and that they resorted to replacing the boiler system for the facility. LA also interviewed R1 who stated that they did not have hot water in 1 of their bathroom showers for a few months. R1 states that their apartment has 2 bathrooms so they were able to get hot water in the other bathroom. R1 states that the hot water has since been restored and they are no longer experiencing any issues. Based on interviews the above allegation is Substantiated. Based on LPAs interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report provided

On 10/14/2024 LPA spoke with W1 over the phone who initially stated that S1 was taking pictures of residents apartments and was stealing blankets from their rooms. LPA requested that W1 send the pictures to them so they could verify this information. LPA never received pictures although W1 said they had access to them. When LPA called W1 back they stated that they have been advised to not discuss the matter further by police. LPA submitted a request to San Ramon Police Department for records related to S1 and any allegations and did not receive anything back. LPA spoke with ED and found that there were no reports of residents missing any blankets or other items from their rooms. Any items that were reported lost for residents were found and deemed to have been misplaced. S1 no longer works at the facility and resigned after taking a leave of absence for 2 weeks. S1 took a leave of absence due to the harassment from the individual making false claims. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/19/2024 at 12:00pm Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit as a result of an Unusual Incident Report received 8/09/2024. LPA met with Regional Operations Specialist, Pari Manouchehri and Health Service Director, Anlisse Ramirez and explained the purpose of the visit. The current census is 140. On 9/9/2024 the department received an unusual incident report that stated " Resident (R1) was climbing walls outside the community and entering neighboring homes. (R1) was not responding to staff while running into the street. (R1) was jumping on parked cars; jumped into a car and was flipping off staff and passersby. Resident had just moved in less than 24 hours prior and had a clear 602, assessment and smooth move in. (R1's) behaviors were a direct contradiction to the totality of information gathered prior to move in." LPA reviewed R1's 602 (Physicians report). The 602 stated that R1 could leave unassisted and R1 was independent. R1 did not sustain any injuries. R1 has since been diagnosed with unspecified Schizophrenia and no longer resides at the facility. On 8/3/2024 and 8/6/2024 the facility retrained staff on elopement procedures. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/19/2024 at 1:05pm Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit as a result of an Unusual Incident Report received 7/22/2024. LPA met with Regional Operations Specialist, Pari Manouchehri and Health Service Director, Anlisse Ramirez and explained the purpose of the visit. The current census is 140. It was reported that on 7/16/2024 R1 had their purse, phone, wallet and its contents stolen by S1. LPA obtained S1's personnel file for review. S1 has since been terminated. R1 did not wish to be interviewed. R1 left their personal belongings in the dining area where S1 took them when no one was around. LPA will return at a later date to conduct another case management visit. Facility retrained staff on reporting requirements and procedures on what to do when finding items at the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 3/27/2024 at 1:50 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue a Case Management visit in regards to an unusual incident report received 2/06/2024. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. It was reported that on 02/02/2024 that a team member allegedly observed another team member push a resident living in memory care. It was found that the incident actually occurred 1/31/2024. Resident was observed to have no injuries or recollection of the event. Resident did not fall as they were near a wall and was able to stabilize thyself. Health Services Director, Anelisse Ramirez-LVN, was called to assess for possible injuries. Assessment resulted in no visible injuries. Resident was asked about the event, which they were unable to recall. LPA interviewed witness S2 with the help of Health Services Director, Anelisse Ramirez to translate. S2 stated that while they were pushing the dish cart from the kitchen R1 was wandering in their briefs and approached S2 to ask a question. S2 responded with "OK" because they do not speak English. S2 then returned to the kitchen and came back out a few minutes later. S2 then observed R1 walking down the hall towards S1 who was looking at their phone. S1 ignored R1. S2 speculates that R1 was asking S1 to go to the bathroom based on the body language of R1. R1 raised their voice repeatedly to get the attention of S1 but S1 maintained looking at their phone. S1 then reached over to the left with phone still in hand to push R1 away. R1 then stumbled and braced thyself against the wall. S2 states that R1 looked down after balancing thyself and then walked away. S1 then made eye contact with S2 and rolled their eyes. S2 later reported what they witnessed. Report continues on LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Resident was in memory care and unable to recall. At the time of visit resident was no longer at the facility. LPA spoke with ED about addressing reporting requirements for mandated reporters and ED informed LPA that they provided S2 as well as all facility staff with a training on the expectations. THE FOLLOWING DEFICIENCIES ARE BEING CITED S1 was observed physically abusing R1 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 02/28/2024 at 1:30PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. The facility’s fire clearance was approved for 140. LPA toured the facility with Caroline Frangieh including but not limited to 10 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 78 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 114.1, 112, 113.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. No citations issued during inspection. Required Annual Inspection incomplete. LPA shall return unannounced to complete the inspection at a later date and time. Exit interview conducted with Licensee. A copy of this report provided to the Licensee via email.

On 2/28/2024 at 11:16 AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 2/06/2024. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. It was reported that on 02/02/2024 that a team member allegedly observed another team member push a resident living in memory care.Resident was observed to have no injuries or recollection of the event. Resident did not fall as they were near a wall and was able to stabilize thyself. Health Services Director, Anelisse Ramirez-LVN, was called to assess for possible injuries. Assessment resulted in no visible injuries. Resident was asked about the event, which they were unable to recall. The staff (S1) alleged of abuse was terminated effective 2/12/2024. LPA obtained a copy of the Disciplinary Action Notice for S1 and contact information for witnesses and all parties involved. LPA will return at a later date to continue investigation. No Deficiencies will be cited at this time Exit interview conducted. A copy of this report provided via e-mail.

On 1/17/2024 at 1:30 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 11/11/2023. LPA met with Executive Director, Caroline Frangieh, and explained the purpose of the visit. It was reported that on 11/10/2023 resident (R1) went awol from facility. At approximately 7:15AM the door alarm near apartment 285 went off. When facility staff went to look for R1 they were not found in their apartment. At approximately 7:30AM R1 was located in facility parking lot. During visit LPA reviewed R1's physicians report and care plan. R1's physicians report states that R1 is able to leave the facility unassisted. Exit interview conducted. A copy of this report provided.

On 10/20/2023 at 12:30 PM Licensing Program Analysts (LPAs) P. Watson and A. Gomez arrived unannounced to conduct a Case Management inspection. LPAs met with Executive Director, Melissa Del Dosso , and explained the purpose of the visit. While LPAs were conducting another visit in the facility, LPAs were informed of the following deficiency. -Facility has an approved fire clearance capacity for 140 residents, however the facilities current census is 143. An immediate civil penalty will be assessed today of $500. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Exit interview conducted, appeal rights and copy of this report provided.

S3 and S4 stated that the facility has taken action to alleviate any odor that has been caused by the disrepair such as opening doors and windows and placing a fan in the kitchen area to blow the smell away from dinning area. S2 and S3 stated that the smell is primarily in the kitchen area and can be smelled when kitchen staff open the doors to deliver food. S5 stated that at one point the odor did linger into the hallway closets to the kitchen area but recently they have not smelled any odors. Based on interviews with residents, R4 stated that they were informed by staff that the exhaust fan in the kitchen was broken and that there may be an odor, R4 stated that they smelled a slight odor in the kitchen area at one point but did not smell anything recently. Based on LPAs observations and interviews, although the allegations may have happened or is valid, the facility is taking action to make repairs and alleviate odors, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.

Allegation: Staff yelled at resident During the course of investigation, LPA conducted residents and staff interview. Based on interview with staff, they denied witnessing or knowing any staff that yelled at the residents in care. Staff stated that they have not witnessed or heard any staff acting inappropriate behavior towards residents in care. Based on residents interview they denied witnessing or hearing any staff yelling at residents in care. Allegation: Facility not providing adequate care for resident During the course of investigation, LPA conducted records review, interview with staff and residents. Records review on physician’s report and care plan revealed that resident (R1) was ambulatory and does not require toilet assist. Staff stated that for residents that needs incontinence care, the care staff checks on them at least every 2-3 hours to meet the residents needs. LPA observed during the visit that residents are comfortable, well dressed and staff are attending to each resident in care. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided

On 3/15/22 at 11:55 AM Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a Pre-licensing Inspection. LPA met with Executive Director, Eugenia Smith and explained the purpose of the visit. The facility currently has residents. The facility's fire clearance is approved for 62 ambulatory, 64 non-ambulatory and 14 bedridden residents. LPA toured facility with Executive Director including but not limited to apartments, bathrooms, kitchen, multiple activity rooms and courtyard. Apartments were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. There is sufficient lighting throughout facility. Hot water temperature was maintained at 117 degrees F in random resident's apartment. First-aid kit was observed to be complete. Smoke detectors are interconnected with sprinklers and observed throughout facility. Carbon monoxide detector was in operating condition Fire extinguisher was last serviced on 6/2/2021. No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required. COMP III was presented to Executive Director. Exit interview conducted. Due to technical difficulties, a copy of this report provided via email.

Facility Type: RCFE Application Type: CHOW Capacity: 140 Census (if any clients in care): yes (40) Method: Telephone call with CAB COMP II Participants: SMITH, EUGENIA Applicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property 8. Discussed the COVID-19 Mitigation Plan & PIN emailed

Facility Type: RCFE Application Type: CHOW Capacity: 140 Census (if any clients in care): (YES) 99 Method: Telephone call with CAB COMP II Participants: ROBERT JAKINI & SUSAN MCPHERSON Applicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property 8. Discussed the COVID-19 Mitigation Plan & PIN emailed