Ivy Park of Belmont

Type of visit: Case Management - Annual Continuation

To complete annual inspection of 9/17/26, LPA Jeung completed review of client records and staff records. Staff training transcripts are provided to LPA for review. No deficiencies of the California Code of Regulations, Title 22 are cited. See Technical Advisory Notes for more information--3 pages.the state’s words, verbatim · CDSS document, Oct 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst Audrey Jeung met with executive director and toured this 3-story facility, consisting of 81 assisted living apartments on 3 floors and 17 memory care apartments on the third floor. All rooms have private bathrooms and all apartments are equipped with Arial emergency call alert devices installed in bedroom and bathroom, which clients use to summon staff for emergencies. The auditory alert is transmitted to a central monitor in the wellness office and to each caregivers' handheld device. Random client rooms were inspected, including common areas--dining, living, activity rooms, public restrooms. There is a secure rear patio. No accessible bodies of water or hazards were observed. Smoke detectors and carbon monoxide detectors were observed to be in working condition. Adequate lighting and comfortable indoor temperature were observed in the facility. Emergency exit routes are marked, and an emergency evacuation plan was posted. Carbon monoxide detectors are tested and operable. Medications are stored in locked medication room. Perishable and non-perishable food supplies are maintained. Annie Buerhaus is a certified RCFE administrator (x 11/26) that oversees facility operations. Random client files are reviewed. Staff files--including training records--will be reviewed at a later time. The following forms are requested to be updated and submitted to CCLD BY 10/1/26: - Administrative Organization (LIC309) - Personnel Report (LIC500) - Hospice plan of operation - Medication plan of operation - Personnel policies - Proof of current liability insurance Deficiency of the California Code of Regulations, Title 22, is observed and cited on a following page.the state’s words, verbatim · CDSS document, Sep 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 24, 2026

MAINTENANCE AND OPERATION 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 delayed egress door in memory care unit (near room 321) does not function properly; door opens immediately and a loud alarm sounds. Licensee failed to ensure that delayed egress door is in good repair, which poses a health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Delayed egress door will be repaired and function with a 15 second delay. Proof of correction to be sent to CCLD BY DUE DATE

Allegation investigated: Licensee does not ensure facility has sufficient staff to provide adequate supervision to residents in care Staff do not ensure call signal systems are responded to in a timely manner Staff does not ensure reporting requirements are being met Staff does not ensure resident receives all of his/her meals Staff does not ensure food is of good quality

On May 26, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit. Regarding the allegation, Licensee does not ensure facility has sufficient staff to provide adequate supervision to residents in care and staff do not ensure call signal systems are responded to in a timely manner, according to the reporting party, there is insufficient staffing and lack of supervision that has resulted in Resident 1 (R1) falling frequently. In addition, according to the reporting party, due to the lack of staffing, residents have to wait longer for staff to respond to their call buttons. During the investigation, LPA interviewed staff, reviewed staff schedule, interviewed residents and reviewed the average call button response times for the entire facility. According to staff interviewed, they are fully staffed and are able to respond to call buttons under 7 minutes. Residents interviewed indicated that staff are great and very responsive when calling for assistance. Based on documents reviewed, the average response time throughout the community is 4 minutes and 15 seconds. (continue to 9099C) Unsubstantiated Regarding the allegation, staff does not ensure reporting requirements are being met, according to the reporting party, the facility refuses to communicate and provide written reports when R1 falls. During the investigation, LPA interviewed staff, reviewed R1’s charting notes, and reviewed facility's internal incident reports. According to Administrator and Health Services Director, they denied this allegation and indicated that R1's responsible party is always contacted after R1 has an incident. Based on R1’s charting notes and facility's internal incident reports reviewed, every time R1 falls, the responsible party is always notified per documentation. Regarding the allegation, staff does not ensure resident receives all of his/her meals, according to the reporting party, staff forgot to bring R1 to the dining rooms for dinner. During the investigation, LPA attempted to interview R1, interviewed staff and reviewed R1’s file. LPA was unable to interview R1 as he/she is no longer a resident at the community. According to R1’s service plan, staff continue to encourage R1 to eat in the dining area, however will offer meal trays if R1 requests to stay in his/her room during meal time. According to staff interviewed, depending on R1's mood that day/time, R1 would either prefer to stay and eat meals in his/her room or would go into the dining room and eat. During a complaint visit conducted on 4/24/26, LPA observed R1 eating lunch in the dining hall. Regarding the allegation, staff does not ensure food is of good quality, according to the reporting party, produce was describes as poor and the meat was described as fatty or low-quality, specifically noting that fish is often served cold. During the investigation, LPA interviewed residents and observed the food menu for the month. Based on the food menu sandwiches get served everyday as an alternative option for residents who do not want to eat the main dish being cooked. Based on observation, LPA visited the facility on 5/26/26 and observed beef brisket quesadilla with sour cream and salsa as the main dish on the menu for lunch. LPA observed residents eating the beef brisket quesadilla or a sandwich if they did not want the quesadilla. According to residents interviewed, the meals served at the facility is good and has not heard complaints about the food. Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.the state’s words, verbatim · CDSS document, May 26, 2026 · control 14-AS-20260420110648

Allegation investigated: Staff admitted residents into the facility with incomplete physician reports Staff did not ensure residents medications were dispensed as prescribed Staff did not ensure care and supervision was provided to resident resulting in an elopement from the facility

On March 11, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit. Regarding the allegation, staff admitted residents into the facility with incomplete physician reports, according to the reporting party, the facility admitted Resident 1 (R1) and Resident 2 (R2) to the facility without ensuring the LIC602 Physician’s Reports were completed. During the investigation, LPA reviewed R1 and R2’s file. Based on the admission agreement reviewed for both residents, the admission agreement was signed on 12/30/25 and R1 and R2 physically moved into the facility on 1/6/25. Based on R1 and R2’s physician’s report, both physician’s reports were completed, signed and dated on 9/5/25. (continue to 9099C) Unsubstantiated Regarding the allegation, staff did not ensure residents medications were dispensed as prescribed, according to the reporting party, because R1 and R2's physician's report was not completed, the administrator indicated that the staff have not been giving R1 and R2 any of their medication. During the investigation, LPA interviewed staff, reviewed charting notes and reviewed fax documentation that was sent to R1 and R2's physician. Based on charting notes reviewed notes on 1/6/26, the facility was awaiting a signed medication and notified R1 and R2's responsible party. Facility staff notified R1 and R2's responsible party to assist with medication administrator until the medication list was signed. According to staff interviewed and fax documentation, the facility sent multiple faxes to R1 and R2's physician to sign R1 and R2's current medication list so medication can be administered by the facility. Additional fax sheets dated 1/9/26-1/12/26 sent to the physician reports that R1 and R2 missed their medication because there were missing medication, missing a signed medication list and needed reconciliation. Regarding the allegation, staff did not ensure care and supervision was provided to resident resulting in an elopement from the facility, according to the reporting party, on 1/10/26, R1 eloped out of the memory care unit and was found at the grocery store and brought back to the facility. During the investigation, LPA interviewed staff and reviewed documents. According to staff interviewed and charting notes reviewed, R1 did not elope from the facility on 1/10/26. On 1/10/26, R1 attempted to elope from the facility, however he/she was found on the facility premises at the back gate and was redirected back to the facility. Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 14-AS-20260112113350

Allegation investigated: Staff did not ensure the facility telephone is properly operating Staff provided a resident an inappropriate heating device Staff did not provide a comfortable temperature for a resident

On March 11, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint visit. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit. Regarding the allegation, staff did not ensure the facility telephone is properly operating, according to the reporting party, on March 2, 2026, he/she received phone calls from the facility's main line, however when he/she tried returning the call, there was no answer. Reporting party indicated that on March 3, 2026, he/she tried calling the facility in the morning again, however there was no answer. During the investigation, LPA interviewed administrator, staff and tested the facility's main number. LPA confirmed that the facility phone is in good working condition. The administrator indicated that she received at call at 11:37pm on 3/2/26, notifying her that the facility's main phone was not working. The administrator immediately notified the Health Services Director who worked with the Resident Care Coordinator early the next morning to fix the facility phones. (continue to 9099C) Unsubstantiated According to the Health Services Director and Resident Care Coordinator, the facility's main phone was not working because on 3/2/26, when the receptionist handed the phone to the med-tech, they did not transfer the phone line properly. In addition, the Resident Care Coordinator confirmed she fixed the phone system on 3/3/26 before 9:30am. Based on documents reviewed, an in-service training was provided on 3/4/26 with med-techs and the receptionists regarding phone hand off. Regarding the allegation, staff provided a resident an inappropriate heating device, according to the reporting party, the administrator provided Resident 1 (R1) a space heater while the heating in R1's room needed to be fixed, however the space heater did not turn off when tipped over. During the investigation, LPA interviewed the administrator, maintenance director, and observed R1's room. According to the Maintenance Director and Administrator, R1's responsible party complained about the temperature gage on the thermostat in R1's room and wanted the room temperature to be 80 degrees F. According to the maintenance director, she checked the room temperature several times and notified R1's responsible party that R1's room was reading between regulatory requirements, however R1's responsible party still complained, so the Maintenance Director not only replaced R1's thermostat but also provided R1 with a space heater to put in his/her room. The administrator indicated when she observed the space heater in R1's room, she had to remove it as the facility does not allow heating devices in resident rooms. Furthermore the administrator stated, even after removing the space heater from R1's room and notifying R1's responsible party that it was not allowed, R1's responsible party brought another heating device to the facility to place in R1's room. During the visit, LPA did not observe a space heater in R1's room. Regarding the allegation, staff did not provide a comfortable temperature for a resident, according to the reporting party, the administrator refused to call an HVAC company to fix the heating in R1's room for over a week. During the investigation, LPA interviewed the administrator, maintenance director, observed R1's room. According to the administrator, she denied this allegation and indicated that she told R1's responsible party that she wanted to try to fix R1's room temperature in house, if possible, prior to calling HVAC. The administrator and the maintenance director, confirmed that R1's thermostat was in good working condition, however R1's responsible party wanted R1's room to read at 80 degrees F. The maintenance director worked with R1 and R1's responsible party by reading R1's room temperature multiple times and replacing the thermostat. (continue to 9099C) According to the maintenance director and administrator, the temperature readings in R1's room were within regulatory requirements, however R1's responsible party still complained so HVAC was called and they came out to do service in R1's room. During the visit, LPA observed R1's room to be at 76 degrees F. Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 14-AS-20260304103141

Type of visit: Case Management - Incident

On January 28, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 1/17/26. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit. The Licensee reported on 1/17/26 at around 1:00am, Resident 1 (R1) told the med-tech while doing round that, he/she was sexually assaulted by staff. No injuries were noted. All required parties were notified. Facility conducted an investigation. During the visit, LPA discussed the incident with Administrator, Health Services Director, Memory Care Director, attempted to interview R1, and reviewed R1's file. Based on R1's file reviewed, R1 has a diagnosis of dementia and metabolic encephalopathy. In addition, based on staff interviewed and records reviewed, R1 does not have any prior incidents at the facility making allegations like this. LPA attempted to interview R1 during the visit, however did not respond to LPA due to dementia diagnosis. R1's responsible party was present at the facility during the visit. According to R1's responsible party interviewed, R1 is very happy at the facility and the staff are really great. In addition, R1's responsible party indicated that R1 has a history of making allegations like this and it might be happening more due to R1's dementia diagnosis. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Facility failed to report incidents and death to CCLD

On October 7, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit. Regarding the allegation facility failed to report incidents and death to CCLD, according to the reporting party, they are unsure if CCLD was notified regarding Resident 1's (R1's) falls and if CCLD was notified regarding R1's death. During the investigation, LPA interviewed staff and reviewed facility's and Department's records. Based on Department's records, although the facility reported R1's death, the facility failed to report R1's falls to CCLD. According to records reviewed, although the facility submitted a death report for R1 to CCLD, the facility did not submit any incident reports to CCLD in regarding to R1. According to staff interviewed and records reviewed, there were internal facility reports regarding R1's falls and hospice and responsible party were notified, however staff indicated that there were at least two instances where hospice ordered hospitalization related to a fall. These falls were not reported to CCLD. (Continue to 9099C) Substantiated LPA reviewed the Department's documents, although, a death report was submitted to CCLD, no incident reports were submitted to CCLD in regards to R1's falls, and the facility was unable to provide fax confirmation sheets to show that incident reports were submitted to CCLD. Based on the interviews conducted, records reviewed and information collected, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided with appeal rights. During the investigation, LPA reviewed R1's file, interviewed staff, and interviewed hospice notes. According to staff interviewed and documents reviewed, R1 had 8 falls within 8 months, and the facility implemented frequent checks that were being conducted every 1-2 hours, in addition to close supervision by bringing R1 into the common area. The facility also removed all fall hazards from R1's room and placed a fall mat in R1's room. Based on R1's file, after each fall, the facility would reach out to hospice and R1's physician for medication adjustments. Regarding the allegation, medication was not administered as prescribed, according to the reporting party, R1 was experiencing anxiety and agitation and was prescribed morphine on an as needed basis to control this condition. Reporting party indicated that the facility was not administering the morphine when R1 needed it. During the course of the investigation, LPA conducted interviews, conducted research, and reviewed pertinent documents related to the allegation. According to interviews and documentation reviewed, there are two Registered Nurses (RNs) and one Licensed Vocational Nurse (LVN) at the facility who were able to provide morphine to R1 as needed as prescribed by the physician, however based on interviews conducted, R1 did not require morphine until he/she was transitioning to hospice and that's when morphine was being prescribed by hospice. In addition, staff interviews indicated that morphine was on standby. Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 14-AS-20250529111732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 14, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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... This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, R1 had falls that resulted in hospitalization, however the facility failed to submit an incident report to CCLD which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Licensee/administrator shall review CCR 87211 and submit acknowledgment to ensure compliance with the regulation.

Type of visit: Required - 1 Year

On August 5, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Business Office Director, Broneesha Bradford and explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story facility; Assisted Living (AL) on the first, second, and half of the third floor and Memory Care (MC) on the other half of the third floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed residents eating lunch, walking around or participating in activities. A comfortable temperature of 74 degrees F is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured 111-118 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars in each bathroom. LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications and sharps were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of March 2025. First aid kits were observed present and complete. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with the Business Office Director and a copy is provided.the state’s words, verbatim · CDSS document, Aug 5, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Prelicensing

On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannonced pre-licensing inspection visit. LPA met with administrator Minnie Weber and explained the purpose of today's visit. This is a three level facility with a memory care are named "Evergreen" which currently there are 17 residents currently residing in. There are 58 residents in assisted living. Seven residents are currently on hospice. LPA toured facility and grounds. This is a three level facility. LPA observed resident rooms at random. All rooms observed contained the required furniture items outlined within regulations including flash lights and non-skid mats in resident showers. Personal protective equipment (PPE) is in place in an exterior storage area outside of the facility. Perishable and non-perishable food supplies are in place. Food preparation and service items are present in the main kitchen and in other food serving areas such as the dining rooms for assisted living and memory care. Hot water temperature is tested at 110F. Carbon monoxide and smoke detectors are hard wired and operable. The facility is fully equipped with fire sprinklers through out all areas in the facility. LPA observed multiple fire extinguishers through out the facility, including the kitchen, with inspection/service date of 01/30/2024. Fire pull stations are located at fire exits. Emergency exit routes are observed to be clear of obstructions inside and outside. Medications are secured in the primary medication room on the second floor. Medications are observed to be locked. Toxins, chemicals, and other cleaning supplies are inaccessible to resident in care. Based on observations made LPA did not observed any such items accessible to residents during this inspection visit today. LPA observed two laundry rooms, one on the ground floor and one on the third floor, and both are operational clean and functioning. The third floor of the facility is where secured memory care is located. There is an outdoor patio on this level that is in good condition and a secured perimeter with furnishings. There are an emergency set of keys in place accessible to staff and emergency personnel if needed. The administrator Minnie Weber is the current facility administrator. LPA requested the required items to have her name transferred as administrator. Component III RCFE orientation is provided to the administrator. This pre-licensing is complete and this facility has no deficiencies. *** AMENDED SECOND PAGE DUE TO ERROR. THIS PAGE SHOULD NOT HAVE BEEN GENERATED AND IS INTENTIONALLY LEFT BLANK ***the state’s words, verbatim · CDSS document, Aug 21, 2024