Ivy Park At Palo Alto

On 08/27/2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to deliver and discuss the findings of the Complaint allegations and investigation. Upon arrival, the LPA met with the Executive Director, Stephanie Brice, and disclosed the purpose of the visit. On 06/16/2025, the department received a complaint with one (1) allegation ‘Facility staff are not safeguarding belongings of resident(s)’. On 06/20/2025, 08/12/2025, and 08/21/2025, the department conducted initial investigations at the facility. On 06/20/2025, 08/12/2025, 08/21/2025, and 08/26/2025, LPA interviewed five (5) staff members (ED, S1-S4), nine (9) residents (R1-R9), and R10’s Primary Emergency Contact (PEC). Continued on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, August 27, 2025 · control 26-AS-20250616122012

On March 27, 2025, at 2:20 PM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Executive Director (ED), Stephanie Brice. The LPA disclosed the purpose of the inspection. The ED informed the LPA that there were (66) residents in care. Regarding the allegation “Staff administered the incorrect medication resulting in a resident's hospitalization”, the Reporting Party (RP) stated “R1 returned to the facility from skilled nursing, and their updated medication list was not sent to the pharmacy causing the staff to administer the wrong medication to the resident. RP reported that the facility administered a medication to the resident that R1 was no longer taking causing severe low blood glucose. RP reported that on 02/17/25, the resident had to be transported to the hospital and was admitted to the ICU. Continued on LIC9099-C SubstantiatedRead the full finding— CDSS inspection report, March 27, 2025 · control 26-AS-20250219092649

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Stephanie Brice, Administrator. On 07/08/2024, the Department received a complaint with the above allegations. On 07/16/2024, LPA Marrufo conducted an initial complaint investigation visit. Resident R1’s Service Plan states R1 requires medication assistance and requires monitoring of weight gain or loss once per week. During interview on 07/16/2024, resident R1 stated that R1 uses a scale to check R1’s weight and records R1’s weight every day in a handwritten log. LPA observed R1’s handwritten daily weight log. R1 stated that R1’s weight scale has not been broken. See LIC9099-C for more information. Page 1 of 3. UnsubstantiatedRead the full finding— CDSS inspection report, December 5, 2024 · control 26-AS-20240708100511

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Stephanie Brice, Administrator. On 06/26/2023, the Department received a complaint with the above allegation. On 06/30/2023, the Department conducted an initial complaint investigation visit. Throughout the investigation, the Department interviewed residents R1-R2, 2 family members of R1-R2, and 8 staff. LPA Marrufo attempted telephone interviews with 2 other staff but was unable to reach them. LPA Marrufo also obtained copies of R1 and R2’s resident records, LIC624 Incident Report, Theft and Loss Policy, LIC621 Client/Resident Personal Property and Valuables form, Emergency Contact Information Forms, and Progress Notes See LIC9099-C for more information. Page 1 of 3. UnsubstantiatedRead the full finding— CDSS inspection report, December 5, 2024 · control 26-AS-20230626112634

On 11/07/2024 Licensing Program Analyst (LPAs) Kiran Jain and Grace Donato conducted an unannounced complaint investigation visit and met with Executive Director, Chris Schuster. LPAs explained the purpose of the visit. Regarding the allegations that the Resident is being neglected due to bruisings, the reporting Party (RP) mentioned that they received a call from a Stanford Hospital Social Worker regarding bruising. Client is a fall risk, has dementia and oriented to person only at baseline. Client had bruising on their right toe, and right cheek bone area that looked consistent with a fall. Client has daytime one-to-one care, but no overnight care. The facility is not sure how the fall occurred as it was unwitnessed. Client's family member reported to the hospital that client has history of falls and had no concerns about the skilled facility's care of client. Client was transported to the hospital the week prior to 10/17/24 for a fall that required stitches from a laceration on theiRead the full finding— CDSS inspection report, November 7, 2024 · control 26-AS-20241024162149

On 11/01/2024, Licensing Program Analysts (LPAs) Kiran Jain and Grace Donato conducted an unannounced complaint investigation visit and met with Health Services Director Baneen Amiri. LPA explained the purpose of the visit. Regarding the allegations that the facility did not assist in providing care with activities of daily living, The facility did not consistently observe changes and address resident's physical, mental, emotional, or social functioning and did not provide appropriate assistance in response to these changes, and the facility did not provide adequate supervision or ensure proper assistance with the administration of medication, the reporting Party (RP) mentioned that Client (R1) has not showered in an unknown amount of time and the home is in disarray. The client has schizoaffective disorder and has not taken her medication in several months. RP attempted to contact the Client and she is very incoherent. RP attempted to evaluate Client for a psychiatric hold, but the ClRead the full finding— CDSS inspection report, November 1, 2024 · control 26-AS-20241004120232

On 9/6/24 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit and met with Health Services Director Baneen Amiri. LPA explained the purpose of the visit. Regarding the allegations of staff physically manhandled the resident that caused bruising on the left forearm and staff hit resident while in care, Reporting Party (RP) mentioned that resident R1 stated that he/she was hit by the staff, and they were roughly handling him/her while getting ready for the day. Per RP, R1 stated staff squeezed his/her left arm and R1 hit the caregiver because of the pain he/she was experiencing and in turn the caregiver hit R1 back on the left forearm. Per RP the squeezing and hitting caused R1 to bruise on the left forearm. con't .... UnsubstantiatedRead the full finding— CDSS inspection report, September 6, 2024 · control 26-AS-20231211152500

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Andrew Pence. During visit, LPA Marrufo toured the garage storage rooms and areas, employee lounge room, and facility kitchen. LPA Marrufo did not observe any alcoholic drink in those areas except for bottles and boxes of alcohol in the facility pantry. LPA Marrufo interviewed staff S1-S11 and residents R1-R6. Staff S1 stated during interview that the facility serves alcohol to residents upon request and if the resident is able to drink alcohol. S1 stated the pantry is locked once meals are done being served. See LIC9099-C for more information. Page 1 of 2. UnsubstantiatedRead the full finding— CDSS inspection report, October 18, 2023 · control 26-AS-20231012133153

LPA Marrufo conducted an unannounced complaint investigation visit and met with Kathleen Olson. On 03/18/2021, the Department received a complaint with the above allegations. On 03/25/2021, the Department conducted an intial complaint investigation visit and conducted further visits on 03/29/2021, 06/30/2023, and 07/06/2023. LPA Marrufo interviewed 8 residents, including R1, 3 resident responsible parties (for 3 out of the 8 interviewed residents who were from memory care), 10 care giver staff, and 3 kitchen staff. R1’s Physician’s Report from 11/27/2019 indicated R1 has a diagnosis of Alzheimer’s Dementia. The Physician’s Report indicates R1 is able to bathe self, dress/groom self, able to follow instructions, and able to communicate needs. The Physician’s Report indicates R1 is ambulatory. See LIC9099-C for more information. Page 1 of 8. UnsubstantiatedRead the full finding— CDSS inspection report, July 6, 2023 · control 26-AS-20210318093226

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Fatima Vicente-Dimanlig, Resident Care Director. On 03/25/2020, the Department received the complaint with the above allegations. On 03/27/2020, LPA Marrufo conducted the initial complaint investigation visit. An Incident Report filed by the facility on 03/24/2020 states that resident R1 was seen by the nurse on duty after R1’s fall on 03/22/2020. The Incident Report states R1 reported having 3/10 pain on R1’s right ankle. An assessment was done and there was noted to be discoloration on R1’s right ankle area. 911 was called for further assessment. Paramedics were unable to determine if R1’s right foot was fractured. R1 initially refused to go to the emergency room, but eventually requested to be taken. R1’s Progress Notes from 03/22/2020 state that at 7:08 AM, staff were trying to assist R1 from R1’s bed to R1’s wheelchair. R1 reported that R1’s knees were feeling weak andRead the full finding— CDSS inspection report, June 22, 2023 · control 26-AS-20200325172553