Ivy Park at Santa Rosa

Allegation investigated: Staff did not prevent physical altercation between residents in care

At approximately 12:50 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to initiate and deliver findings for a Complaint Investigation regarding the above allegation and met with facility Executive Director (ED) Limberg. LPA requested documents and conducted interviews. Complaint alleges Staff did not prevent physical altercation between residents in care. On 3/27/2026, two (2) Memory Care residents were involved in an altercation. Resident R1 was witnessed hitting resident R2 on the shoulder four (4) times. As staff member S1 attempted to intervene, resident R2 threw their hand up which caused them to loose balance and fall. Resident R2 hit their head during the fall. The facility immediately notified Emergency Services and contacted the Santa Rosa Police Department (SRPD) to report the incident. SRPD investigating Officer O1 arrived shortly thereafter. Continued on 9099-C... Unsubstantiated ...Continued from 9099 In an unredacted Incident/Investigation Report for Case #SR260003153.0, Officer O1 stated that both resident R1 and R2 did not remember the incident happening and that they were unable to obtain any more information regarding the incident. In the Incident/Investigation Report, Officer O1 stated that because neither resident R1 or R2 remembered the incident, they did not believe a violation of California Penal Code (CPC) 368(b)(1) occurred. CPC 368(b)(1) is defined as a criminal offense of elder or dependent adult abuse. Resident R2 was transported to the Emergency Room where a CT (Computed Tomography) Cervical Spine scan, CT head scan and chest X-ray were performed. All results were negative. Resident R2 returned to the facility in the afternoon on 3/27/2026. As regulations require, the facility filed an LIC 624 Unusual Incident/Injury Report and filed a SOC 341 Report of Suspected Dependent Adult/Elder Abuse with Community Care Licensing. The facility contacted family members and the Primary Care Physicians (PCP) for both residents R1 and R2. Additionally, the Long-Term Care Ombudsman was contacted. LPA reviewed all Incident Reports filed by the facility for 2025 and 2026 and observed that there have been no previous Incident Reports or any Incident Reports after the 3/27/2026 event filed involving any altercations between residents R1 and R2. Facility ED Limberg confirmed that there have been no further altercations between the two (2) residents. So, 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. Exit interview conducted. Copy of LIC-9099 and LIC-9099C discussed and provided to ED Limberg. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 21-AS-20260724160942

Type of visit: Required - 1 Year

At approximately 9:30 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by Administrator/Executive Director (ED), Stephanie Limberg. Ivy Park at Santa Rosa serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 114 non-ambulatory residents of which 14 residents may be bedridden. Facility has an approved hospice waiver for 12 residents. The facility consists of two (2) multi-level buildings. One (1) building is for assisted living. The other building is dedicated to memory care. Upon arrival, LPA was informed that there were one hundred one (101) Residents in care. At approximately 9:50 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:20 AM, LPA reviewed ten (10) resident files. Ten (10) of ten (10) resident files were observed to be well organized and thorough with all required documentation. LPA reviewed ten (10) staff files. Ten (10) of ten (10) staff files were observed to be well organized with all required documentation including First Aid and CPR certification and proper training documentation. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Limberg. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 27, 2026

Type of visit: Case Management - Incident

At approximately 2:45 PM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit and met with facility Executive Director (ED), Stephanie Limberg. On 1/22/2026, Community Care Licensing (CCL) received an LIC 624 Unusual Incident/Injury Report regarding resident R1. LPA interviewed facility Executive Director Stephanie Limberg. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Limberg. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Incident

At approximately 2:45 PM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit and met with facility Executive Director (ED), Stephanie Limberg. On 1/18/2026, Community Care Licensing (CCL) received an LIC 624 Unusual Incident/Injury Report regarding resident R1. LPA interviewed facility Executive Director Stephanie Limberg. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Limberg. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 29, 2026

Allegation investigated: Staff are not giving resident medications as prescribed Personal Rights

At approximately 11:35 AM, Licensing Program Analyst (LPA) Robert Frank conducted an unannounced visit and met with Administrator Stephanie Limeberg. LPA came to the facility to investigate complaint allegations listed above. During today's visit, LPA learned that involved parties including resident does not reside and never have been present at the facility. LPA was unable to identify any deficiencies at this facility. The allegation about personal rights and staff are not giving resident medications as prescribed are UNFOUNDED. An allegation that is UNFOUNDED, means that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Dec 18, 2025 · control 21-AS-20251212112334

Allegation investigated: Staff did not safeguard resident funds

Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegation and met with Executive Director (ED) Stephanie Limberg. During the investigation LPA interviewed facility Administrator, one (1) resident, and reviewed files. The complaint alleges that the staff did not safeguard resident funds. The alleged theft occurred on 6/9/2025. The facility self reported the incident to Community Care Licensing (CCL) on 6/10/2025 by submitting an LIC 624 Unusual Incident/Injury Report and an SOC 341 Report of Suspected Dependent Adult/Elder Abuse form. On 6/10/2025 the facility reported the alleged theft to the Santa Rosa Police Department. The report was filed online as the Santa Rosa Police Department requires that all thefts, under five-thousand dollars ($5,000) and without a known suspect be reported in this manner. The Santa Rosa Police Department case number is SR250L00544.0. The Santa Rosa Police Department did not come to the facility to investigate the alleged theft. Continued on 9099-C... Unsubstantiated ...Continued from 9099 Resident R1 left the facility for an outing on 6/9/2025. When R1 returned they left the allegedly stolen money in their apartment and went to the dining room for a snack for approximately one (1) hour. When they returned to their apartment, they discovered that the money was not where it was left. During the time frame of the alleged theft, there were nine (9) staff members that had the ability to access R1’s apartment. This number does not include executive staff. The facility does not have a video monitoring system. As there is no video or forensic evidence available, LPA was unable to ascertain who committed the alleged theft. So, 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 today's visit. Exit interview conducted. LIC 9099 and LIC 9099-C discussed and provided to ED Limberg. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 21-AS-20250730131807

Type of visit: Required - 1 Year

At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by Office Director Debbie Spencer. Administrator/Executive Director (ED), Stephanie Limberg arrived at approximately 8:55 AM. Ivy Park at Santa Rosa serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 114 non-ambulatory residents of which 14 residents can be bedridden. Facility has an approved hospice waiver for 12 residents. The facility consists of two (2) multi-level buildings. One (1) building is for assisted living. The other building is dedicated to memory care. Upon arrival, LPA was informed that there were 100 Residents in care. At approximately 9:10 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:00 AM LPA toured the facility with ED Limberg. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a variety of menu options for the residents at each meal. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of nine (9) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation. Continued on 809-C ...Continued from 809 Both buildings' smoke and carbon monoxide detectors and sprinkler system were last inspected 12/2024. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged 1/10/2025. The facility conducts disaster drills monthly. The last disaster drill was conducted on 3/20/2025. LPA conducted a sample file review of ten (10) staff members. All staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for ten (10) residents. Upon review, LPA observed residents to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to residents in care. LPA conducted a spot check of 8 residents’ medications both in memory care and assisted living and observed all documentation and medications to be in order. During the tour, residents were observed interacting with staff in common spaces, resting in their private apartments, participating in various activities and mingling with family and amongst each other. The Facility has a library, billiards room, and a small store for the residents. There is also a beauty salon for the residents that operates several days a week. The facility provides an eclectic range of activities specified for both assisted living and memory care engagement. Stephanie Limberg’s Administrator Certification 7004545740 is current with an expiration date of 7/6/2026. LPA is requesting the following documents submitted to CCLD by 4/25/2025: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Copy of Current Liability Insurance No deficiencies cited during today's visit. Exit interview conducted. Copy of report and discussed and provided to ED Limberg. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 25, 2025

Type of visit: Required - 1 Year

At approximately 8:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Receptionist, Sony Pastor. Administrator/Executive Director, Stephanie Limberg, arrived during visit at approximately 8:45AM. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 114 non-ambulatory residents of which 14 residents can be bedridden. Facility has an approved hospice waiver for 12 individuals. Upon arrival, LPA was informed that there were 102 Residents in care and 32 staff members on-site. At approximately 9:10AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:55AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: Facility consists of two buildings, one for Assisted Living, and one for Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 12 sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility's fire sprinkler system was last inspected March 2023. Facility's last emergency/disaster drill was conducted March 2024. At approximately 11:55AM, LPA reviewed resident files. Files were all found to be well organized, thorough and contained the required documentation. Administrator's Certificate for Stephanie Limberg (6015704740) was current with an expiration date of 07/06/2024. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 25, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Stephanie Limberg, Administrator. Facility currently has 101 residents in care.. On 1/31/2024 CCL received from facility a SOC341 report of abuse, type of abuse reported is sexual assault. Suspected abuser is unknown. At approximately 1:45pm on 1/31/2024, resident (R1) reported to Admin they were sexually assaulted. R1 reported that the suspect entered their apartment, put a hand over their mouth, held them down and assaulted them. Admin notified Santa Rosa Police Dept (event #SR24-1243) immediately upon reporting of assault. R1 transported to hospital for evaluation at approximately 4:35pm on 1/30/2024. Description of suspect was given to Admin and authorities. Per LPA interview with Admin, no one on staff matches that description. Admin also notified R1's responsible party at approximately 2:01pm and 4:35pm. R1 discharged from hospital on 2/1/2024 and is currently residing with responsible party at a hotel. No definitive return date to facility has been determined or communicated, as of today. LPA requested hospital discharge information, updated LIC602, updated Care Plan, and police report. Per Admin, hospital refused to provide them with discharge information. Therefore, an updated care plan is not available. Per Admin, police report not available yet. LPA to request police report. Updated LIC602 will be provided to CCL once by Admin. LPA obtained documents and made observations. LPA will follow up with assigned detective and will return to facility for follow-up. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Feb 2, 2024

Type of visit: Case Management - Incident

At approximately 12:55pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report (IR) received on 01/08/2024. LPA was greeted by greeter at front desk. Stephanie Limberg, Administrator met LPA shortly after LPA arrival. On 01/08/2024 CCL received SOC341 reporting abuse of resident (R1) by way of self-neglect. This abuse resulted in 72 hour hold and hospitalization. Admin cross reported incident to police, police report #24-271 was filed. Copy of police report not currently available. On 1/6/2024 at approximately 9:30pm R1 jumped out their apartment window, located on the second floor of Assisted Living. Staff called 911 and notified Admin immediately. R1 was transported to Santa Rosa Memorial Hospital (SRMH) via ambulance. Admin immediately notified POA and PCP. Per LPA interview with Admin, as of today, R1 remains at SRMH. R1 has a fractured back resulting from fall. Per R1's POA, R1 will not be returning to the community; the plan is to find an appropriate new community in which R1 can reside. As of now, a definitive move-out date for R1 has not been determined. If R1 does return to Ivy Park community, R1 will be reassessed prior to discharge from SRMH to ensure her care needs can be met by staff. At approximately 2:00pm LPA reviewed R1's Care Plan, Charting Notes, LIC602, and Behavior intervention record. Per Care Plan: resident is at high risk for falling. Fall risk to be mitigated by staff, encouraging R1 to use walker and sit on walker if feeling dizzy. R1 exhibits attention seeking behavior relating to medical attention and 911 services. R1 talks about wanting to die and expresses negative thoughts to others. Per charting notes: resident often claims they aredying (not that they wantto die), resident's typical behavior fluctuates between negative attention-seeking behavior and self-isolation in their room. While self-isolating, resident displays various symptoms of depression. Resident pushes pendant very often, including when caregivers are already present and assisting her in her room. Resident often makes statement claims to staff related to medical misperceptions. On 12/25/2023 resident had an unwitnessed fall for which they were sent to the ER, hip and lumber spine normal per xray. Continued on 809C... Continued from 809C... Per LIC602: resident is ambulatory, has a history of depression and anxiety as well as suicidal/self-abuse, needs assistance with some ADLs, and is not able to leave facility unassisted. Per LPA interview, Admin took immediate action to mitigate future incidents of a similar nature by fitting all windows in Assisted Living with safety restrictors that prevent windows from opening more than five [5] inches (windows in Memory Care already fitted with window safety restrictors). Also, additional staff training conducted on suicide precautions and ideation. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Jan 17, 2024

Type of visit: Case Management - Incident

At approximately 12:50pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report (IR) received on 12/15/2023. LPA was greeted by Stephanie LImberg, Administrator. On 12/15/2023 CCL received SOC341 reporting abuse of resident (R1) in the form of theft of a cellphone. Admin cross reported incident to ombudsman and a police report was filed. Admin contacted Santa Rosa Police Department via telephone number 707.528.5222 at approximately 1:00pm on 12/14/2023 and was advised to submit an online report. Admin filed online report (report number SR230015983) at approximately 3:45pm on 12/14/2023. Per LPA interview with Admin, on 12/14/2023 Admin was notified by resident's family member (I1) that cellphone belonging to R1 could not be located. I1 reported to Admin that they first noticed R1's cellphone missing about 2-3 months ago but did not say anything. I1 reported to Admin that R1's phone was not actually utilized as a typical phone in that R1 did not use it to make phone calls. I1 indicated the phone was utilized as an alarm that would serve as a reminder for R1 to eat meals. Per Admin, on some day in September, R1's cellphone was accidentally washed by the staff. Upon realizing the phone had been put through the wash cycle, staff put the phone in rice to dry out. After the phone had been sufficiently dried, staff returned the cellphone to R1. Staff witnessed R1 place cellphone on its charger. Subsequently, staff notified I1 of R1's phone being washed, dried, and given back to R1. This is the last time the phone was seen; R1's apartment is its last known location. I1 reported to Admin that despite the phone being missing I1 was still paying for the cellphone service. I1 attempted to reactivate phone in hopes of finding its location. Upon speaking with the cellphone carrier's representative, I1 was informed that someone attempted to put in a new SIM card, so the phone is now locked out. Upon learning this, I1 notified Admin that R1's phone was stolen. However, I1 could not provide date of attempted SIM card replacement nor the date on which I1 called the cellphone carrier. Continued on 809C... Continued from 809... Per Admin, R1's apartment was searched by Admin, facility staff and I1, all parties unable to locate the cellphone. Cellphone carrier unable to locate the cellphone remotely. Approximate value of cellphone is $400. Upon arrival of LPA today, Admin provided LPA copies of: Santa Rosa Police Department Summary Incident Report, R1's Care Plan, R1's LIC602, and R1's Client/Resident Personal Property and Valuables list completed at time of R1's admission to the facility. LPA reviewed all provided documents. LPA observed R1's care plan to indicate that R1 requires meal-time reminders, staff are therefore tasked to remind resident to attend meals. Per care plan, R1 can ambulate to dining room without assistance and maintains ability to attend meals in the dining room; staff to help R1 to maintain independence in dining. LPA reviewed R1's Client/Resident Personal Property and Valuables list. List was blank, no valuables listed. List was signed by R1's POA and dated 8/9/2021. LPA interview with Admin and LPA review of police report, R1's Care Plan, R1's LIC602, and Inventory of items Admin has conducted an investigation, cross-reported incident to appropriate parties, and filed a police report upon being notified of missing cellphone. No deficiencies cited during this investigation.the state’s words, verbatim · CDSS document, Jan 4, 2024

Type of visit: Case Management - Incident

At approximately 3:00pm LPAs Christi Coppo and Victoria Bertozzi arrived unannounced to conduct a case management regarding Incent Report received on 10/06/2023. Per facility’s Incident Report: On 10/05/2023 a visitor came to visit resident (R1), upon looking for R1 it was discovered that R1 was not in the facility. The last time R1 was accounted for was at approximately 2:15pm while engaging in activities in the community living room. R1 has a diagnosis of dementia and resides in Memory Care. Staff located R1 at approximately 5:15pm at the Santa Rosa Memorial Hospital Emergency room. R1 was evaluated at the hospital’s ER and was found to have no injuries, no new diagnoses, or new medication orders. R1 was released from hospital’s ER at approximately 6:07pm. LPAs reviewed R1’s assessment and clarified resident has known exit seeking behavior. Per LPAs’ conversation with Administrator, facility immediately conducted additional training with staff. Also, Administrator has increased staff monitoring of R1. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. This report was reviewed with Administrator and Appeal rights were given.the state’s words, verbatim · CDSS document, Oct 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 20, 2023

87705 Care of Persons with Dementia (c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: based on document review, Licensee did not meet requirement by R1 eloping a locked memory care unit. This poses a potential Health, Safety or Personal rights risk to residents.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Facility immediately conducted additonal training with staff. Also, Adminstrator has increased staff monitoring of R1 and increased activities. Deficiency is cleared.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Case Management-Incident inspection to discuss three incidents that were reported by the facility to CCL, and to also Amend a Report that was issued on August 30, 2023 in which a Type A deficiency was issued. Facility appealed, and CCL determined that a Type B deficiency is warranted instead. LPA changed the deficiency from a Type A to a Type B deficiency (See LIC 809-Case Management-Incident inspection dated for August 30, 2023) CCL received an incident report on September 20, 2023 indicating a residents jewelry went missing. Administrator contacted the appropriate parties which includes the Responsible Party via email. LPA requested the following documents: -LIC 602 CCL received an incident report on September 25, 2023. Resident had a left hip fracture due to falling off a chair that was placed in his apartment. Administrator contacted the appropriate parties which includes the Responsible Party. Resident was not a fall risk and there were no prior fall incidents regarding this resident. Facility will reassess resident and determine what additional needs (if any) are needed for this resident. CCL received an incident report indicating a fall that occurred on September 27, 2023 indicating that there was one rodent (rat) that was an apartment. Administrator cleaned, fumigated and eradicated the room. In addition, facility hired a pest control company to ensure that there was no rodent infestation. LPA requested the following document: -Eco-Lap pest control receipt No deficiencies were observed or cited during today's Case Management-incident inspection. Exit interview was conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Oct 3, 2023