The Ivy at Berkeley

Allegation investigated: Staff did not ensure resident’s call button was not in disrepair Staff inappropriately took resident’s medication Staff did not effectively communicate with resident

On 8/12/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM/ED). LPA explained the purpose of the visit with ADM/ED. This is an AMENDMENT to original complaint delivered on 07/21/26. During investigation, LPA interviewed reporting party (RP), resident (R1), staff (ED, S1), Ombudsmen (OMB1, OMB2) and obtained the following documents: Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, Needs & Services plan, Assessment/Pre-appraisal report, After Discharge Summary report, Progress Notes, emails between RP and ED. Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not ensure resident’s call button was not in disrepair Investigation Finding: Substantiated During investigation, LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED, S1, S2, S5) and reviewed R1’s documents. On 04/23/26, staff (S1, S2) confirmed with LPA that they did not test the emergency call button issued to R1 during the onboarding process on 03/27/26 to ensure it was operational. R1 pressed the emergency call button around 5PM the same day and was unable to reach staff for assistance for over 3 hours (5PM to 8:15PM) due to a non-operating emergency call button. R1 stated she was left in the dark, was unable to transfer from her wheelchair to the bed and did not have her meal during this time. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not ensure residents call buttons were not in disrepair was found to be substantiated. Allegation: Staff inappropriately took resident’s medication Investigation Finding: Substantiated During investigation, LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED, S1, S5) and reviewed R1’s documents. On 04/01/26, POA/RP sent an email approving staff medication management for R1. On 04/03/26, he rescinded the approval via email. On 04/07/26, staff confirmed with LPA that they took R1’s medications despite the 04/03/26 email stating that R1 does not require medication management. Her medications were returned before 7PM on 04/07/26 as requested by POA. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff inappropriately took resident’s medication was found to be substantiated. Continued on next page, LIC 9099-C pg2 Allegation: Staff did not effectively communicate with resident Investigation Finding: Substantiated During investigation, LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED, S1, S2) and reviewed R1’s documents. R1 stated that on 03/31/26, she waited for over an hour at the front desk for her scheduled post-surgical transport which she booked in advance. S4 stated they did not notify R1’s POA about the situation on 03/31/26 for an alternate solution. Lack of communication with R1’s POA on 03/31/26 resulted in R1 waiting a long time and finally being told after waiting for over an hour that her transport was cancelled since no caregiver was available to accompany her to her doctor’s appointment. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not effectively communicate with resident was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff did not ensure resident had transportation for appointment Investigation Finding: Unsubstantiated LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED), Ombudsmen (OMB1, OMB2) and reviewed R1’s documents. LPA interviewed R1 who stated that on 03/31/26, staff failed to transport her to a post-surgical appointment she had arranged in advance because she assumed a caregiver would accompany her to her doctor’s appointment which the facility could not provide. ED stated she communicated to R1’s POA that she would oversee R1’s post-surgical rescheduled doctor’s appointment to ensure it was done. However, staff communicated to ED that R1 cancelled her rescheduled post-surgical doctor visit transport because she told staff that her responsible party (POA) will take her instead. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not ensure resident had transportation for appointment is unsubstantiated. Allegation: Staff are not responding to residents’ call buttons in a timely manner Investigation Finding: Unsubstantiated LPA D Panlilio interviewed reporting party (RP), resident (R1), staff (ED), Ombudsmen (OMB1, OMB2) and reviewed R1’s documents. During visit on 04/23/26, LPA tested R1’s call button and staff appeared within 10 minutes of the call button alert. On 07/06/25, OMB1 and OMB2 confirmed with LPA that they tested residents’ call buttons on 04/19/26 and staff showed up within 10 minutes of the call button alerts. LPA interviewed random residents (R2, R3) who stated they did not have any concerns regarding staff responding to call button alerts because they respond within 10 minutes.. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not responding to residents’ call buttons in a timely manner is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 15-AS-20260417112651

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 21, 2026

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 was not met as evidenced by staff not ensuring resident’s call button was operational which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: By POC due date, ED agrees to complete and submit to CCL in-service staff retraining on ensuring residents’ call buttons are operational prior to issuing to new residents and to ensure residents’ personal rights to proper care, supervision and services are in compliance with Section 87303(a) regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(1) · Plan of correction due date: Aug 21, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by staff failing to follow POA’s current written medication management communication which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: By POC due date, ED agrees to complete and submit to CCL in-service staff retraining on proper implementation of written medication management requests in compliance with Section 87468(a)(1) regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Aug 21, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs This requirement was not met as evidenced by staff failing to timely communicate with resident’s responsible party on medical transportation requirements which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: By POC due date, ED agrees to complete and submit to CCL in-service staff retraining on timely communication with residents’ responsible party on medical transportation needs in compliance with Section 87468.1(a)(8) regulations.

Allegation investigated: Staff do not ensure residents are provided a safe and comfortable environment

On this day, 6/3/26, at 12:00 noon, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an initial 10-day investigation of the above allegation and close the complaint. LPA met with Executive Director Angeles Sticka and informed them of the reason for the visit. During the course of the investigation, LPA obtained copies of the staff schedule and the resident roster. LPA obtained copies of, including but not limited to the following: Fire alarm inspections, including carbon monoxide, email communication between S2 and the company. LPA conducted interviews with Staff 1 (S1), Staff 2 (S2), and Staff 3 (S3). LPA conducted an interview with Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), Resident 4 (R4), Resident 5 (R5), Resident 6 (R6), and Resident 7 (R7). LPA conducted an interview with W1. LPA toured the facility, including but not limited to apartments, bathrooms, kitchen, common area, rooftop, and patios. Report continued on LIC 9099c… Unsubstantiated Report continue... It was alleged that the staff does not ensure residents are provided a safe and comfortable environment. RP stated that the pipe's rooftop power generator faces the facility vent that blew into the resident's room, causing the room to smell like car exhaust. During an interview with S2, an R1 family member mentioned the situation on 4/27/26. S2 follow up with the facility owner on 5/11/26 regrading the concern of R1 family member. S2 contacted the company (Melgar Mechanical) that installed the exhaust pile on 5/14/26. The company came out to inspect the issue on 5/21/26 and returned on 5/29/26 to reposition the pipe. The carbon monoxide check document by Cimino Electric Company and Academy Fire Protection, dated 2/7/25, showed that the carbon monoxide system was in working order. LPA observed that there is no smell in the residents' room and that the exhaust pipe is facing away from the rooftop vent of the facility. R1, R2, R3, R4, R5, R6, R7, and W1 all stated that there is no smell in their room. R1, R2, R3, R4, R5, R6, and R7 stated that they feel safe in the facility and that the facility environment is comfortable. Based on interviews, record review, and LPA observation, the facility staff is providing a safe and comfortable environment. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted, and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 15-AS-20260529091241

Type of visit: Required - 1 Year

On 05/07/2026 at 10:00 AM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge conducted an unannounced 1-Year Required inspection. LPAs met with Brenda Silva, Health Services Director, and explained the purpose of the visit. LPAs toured the facility including but not limited to apartments, bathrooms, kitchen, common area and backyard and patios. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. LPAs observed lighting in all hallways are adequate for the comfort and safety of the residents. Hot water temperature in the shared bathroom was measured at 118 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day non perishables and 2-day perishables foods. Continue on LIC 809C CONTINUED FROM LIC809 Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/09/2025. Emergency Disaster Plan was posted 05/07/2026. First aid kit was observed to be complete. Emergency Drills are conducted monthly. Last fire drill was conducted on 01/20/2026. Fire sprinkler system last service 02/02/2025. LPAs reviewed five (5) resident files and five (5) staff files. All were complete. LPAs requested the following documents to be submitted to CCLD by 05/15/2026. · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 610E Emergency Disaster Plan (9 pages) · Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 7, 2026

Type of visit: Case Management - Health Checks

On 04/17/2026 at 4:45 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check. LPA met with Health Service Director Brenda Silva and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, memory care unity and outdoor area. LPA observed residents to be appropriately groomed and attired with no visible bruising or marks. LPA observed no trash piled, electricity and gas operational. Water temperature measured in a common bathroom was 118.5 degrees Farenheit. One week supply of nonperishable and 2-day supply of perishable foods were available. Fire extinguisher last services on 08/09/2025. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 17, 2026

Type of visit: Case Management - Incident

On 01/29/2026 at 9:40 AM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incident that occurred on 01/09/2026. LPA met with Executive Director (ED), Angeles Sticka, and explained the purpose of the visit. On 01/20/2026, LPA P. Manalo received an incident report that indicated that on 01/09/2026, R1 AWOL’D from the facility. Incident report revealed that facility staff seen R1 down the street. Facility staff conducted a search around the neighborhood for R1 and found R1 at bank nearby. Per incident report, R1 did not sustain any injuries. During the visit, LPA interviewed ED and R1. ED stated that R1 went to the bank so that R1 can pay for R1's rent to the facility. ED stated that a fax report was sent to the physician to follow up on R1's diagnosis. LPA reviewed and obtained documents including but not limited to resident roster, incident report, physician report, resident assessments, physician fax report, resident information form, and a copy of the check's invoice that R1 made to the facility. Physician report dated 11/23/2025 indicated that R1 has intermittent confusion and is not able to leave the facility unsupervised. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 13, 2026

(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when R1 AWOL’D from the facility which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: The Executive Director agrees to have an in-service on elopement with the concierge staff and send proof to CCLD by POC date.

Type of visit: Case Management - Incident

On 11/05/2025 at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident reported to Community Care Licensing Division (CCLD) on 10/22/2025. Upon arrival, LPA met with Executive Director (ED) Angeles Sticka and explained the purpose of the visit. LPA obtained the following documents: Resident Roster, Resident Information Sheet, medical assessment dated (07/02/2025), Memory Care Staff schedule (week 10/12/25), In-Service "Elopement Drill" training staff sign-in sheet (dated 10/18/25 and 10/22/25), and Individualized Service Plan (dated 10/28/25). LPA interviewed Staff (S1) who stated that on 10/17/2025, Resident (R1) eloped from the Memory Care (MC) unit. S1 reported that MC staff on duty did not observe R1 leaving the secured unit. According to S1, R1’s granddaughter was the individual who discovered that R1 was missing from their apartment and could not be located within the MC unit. S1 stated that staff immediately initiated the facility’s elopement protocol, which includes: conducting a search of the MC unit and resident apartments. Checking the Assisted Living (AL) apartments, common areas, and the remainder of the building. Conducting an external neighborhood search. Contacting 911 if the resident cannot be located. LIC809-C Continued... LIC809-C (Page 2) S1 reported that staff contacted the Berkeley Police Department, and shortly thereafter, the facility received a call from Agrodolce Osteria, a local restaurant located on Shattuck Avenue, informing staff that R1 was at their establishment. R1’s daughter retrieved R1 from the restaurant and returned them safely to the facility. S1 further stated that R1 has eloped twice to date, with the 10/17/2025 incident being the most recent occurrence. In response, the facility implemented door alarms on all emergency exits and conducted in-service training with MC staff on 10/18/2025 and 10/22/2025 regarding elopement procedures and resident supervision. S1 also indicated that a 1:1 companion was arranged for R1 for five days following the incident; however, the family declined to continue the service due to the cost. S1 added that R1 was later observed walking on Milvia Street, but staff are still unsure how R1 managed to exit the MC unit and the building. LPA reviewed R1’s Medical Assessment (MA), which indicated that R1 was able to leave the community unsupervised. LPA discussed this MA with S1, who confirmed that the response on the assessment was not accurate and did not reflect R1’s current condition or supervision needs. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Nov 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 19, 2025

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ... This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above by not ensuring that Resident (R1) was provided safe and secure accommodations to meet their needs when R1 eloped from the Memory Care unit on 10/17/2025 without staff knowledge or supervision. This posed an immediate health and safety risk and personal rights to R1, who was later located off facility premises by family.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: Administrator and Memory Care Director agreed to arrange a care conference with R1's responsible party to finalize an updated care plan that reflects R1's care needs. Administrator will conduct an In-Service training with all staff and will submit participant sign in sheet, updated care plan and medical assessment to CCLD by POC due date.

Type of visit: Prelicensing

On 05/12/2025 around 10:00 AM, Licensing Program Analysts (LPA) L. Holmes arrived announced to conduct for a return visit to complete a Pre-licensing Inspection on 05/05/25. Upon arrival, LPA was greeted and met with Angeles Sticka, Executive Director (ED) The facility is approved for a capacity of 138; 134 may be non-ambulatory and 4 bedridden. LPA toured the perimeter of the facility and checked Guardian for personnel association. CORRECTION: -All staff, in addition to corporate members, need to be associated to the facility prior to working at the facility LPA observed that the 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's license remaining pending and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided to Angeles Sticka, Executive Director.the state’s words, verbatim · CDSS document, May 12, 2025

Type of visit: Prelicensing

On 05/5/2025 around 9:30 AM, Licensing Program Analysts (LPA) L. Holmes arrived unannounced to conduct a Pre-licensing Inspection. Upon arrival, LPA was greeted and met with Angeles Sticka, Executive Director (ED) and Andrew Moret, VP of Operations. The facility is approved for a capacity of 138. The facility has a secured, keyless entry at the entrance with a concierge station, bistro, and common area. LPA, VP of Operations, and ED toured facility and met with the Director of Wellness where the first aid kit was complete; medication and residents' electronic and paper files will stored and locked in Wellness unit also. The facility consists of six (6) floors, the 2nd floor is dedicated to Memory Care (MC), and the lower level has the Emergency Evacuation plans in place per designated zones. Throughout the facility are activity calendars, game rooms, terraces, courtyards, individual apartments, staff offices, and a parking structure. The apartments are equipped with proper furnishings, adequate lighting, grab bars and non skid surfaces. The model room's temperature was maintained at 70 degrees F. and the hot water temperature was measured at 110.5 degrees F; routine maintenance checks are performed daily. There is a sufficient supply of 7-day non-perishable and 2-day supply of perishable foods. Smoke detectors and carbon monoxide units were operational during visit and are monitored by the Fire Department. Fire extinguisher was last serviced on 03/24/25. Component III was reviewed and completed with ED, and VP of Operations. Continued on LIC809C... ...continude fron LIC809. CORRECTIONS OBSERVED: -The numeric address of the building's facade is 2501 Milvia St. Prior to Operation, visible signage for the address on record will be present. -All staff need to be associated to the facility prior to working at the facility -STD850 to be confirmed/updated by the City of Berkeley's Fire Marshall - Central Applications Unit (CAU) to update comments on on the license LPA observed that the facility is not 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. Exit interview conducted and a copy of this report provided to Andrew Badoud, Executive Director.the state’s words, verbatim · CDSS document, May 5, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 05/05/2025 around 03:00 PM, Licensing Program Analysts (LPA) L. Holmes conducted a Component III for a Pre-licensing inspection on 05/05/25. LPA was greeted and met with Angeles Sticka, Executive Director (ED) and Andrew Moret, VP of Operations. LPA discussed the importance of attending the informational calls, understanding the updated guidelines and printing the provider information notices (PINS) for residents, infection control, and continuous communication with authorized representatives and staff so that the facility maintains awareness and updates for compliancy for the State of California Title 22 regulation, and Health and Safety Codes. -Component III completed. Exit interview conducted and a copy of this report provided to Angeles Sticka, Executive Director (ED).the state’s words, verbatim · CDSS document, May 5, 2025