Ivy Park at San Tomas

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.This was not met as evidenced by: Based on interview and records reviews, on 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026 the ED stated she is unable to locate R1s documentation in storage.

Record centrally stored prescriptions and refill data

Based on records reviewed, the licensee did not comply with the section cited above. LPA noted R1, R2 and R3 had medications that were not listed on the centrally stored medication record. LPA showed the discrepancy to the health services director Kyleigh Whitely but no documentation was provided to verify that the medications in question were included in each corresponding centrally stored medication record. which poses/posed a potential health, safety or personal rights risk to persons in care.

Personal assistance and care for required daily activities

87464(f)(4) Basic services shall at a minimum include:(4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal... activities of daily living such as dressing, eating, bathing and assistance...this requirement was not met as evidenced by: Based on interview and photo,S1, S2 stated the facility was short staffed and the R1s laundry did not get washed. S1 stated R1 had to wear dirty clothing. RP provided photo R1 had soiled clothing on two seperate occasions 09/20/24, and 09/22/24. This posed a potential risk to the health and safety of residents in care.

Call 9-1-1 for imminent health threats

87465(g) Incidental Medical and Dental Care:(g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including…apparent life-threatening medical crisis…This requirement is not met as evidenced by: Based on interview and record review, facility staff did not seek timely medical care for R1. On 08/05/24 R1s were recorded calling for help from 0400 to 0730 hrs. Staff were recorded coming into the R1s room at 0730 hrs. and 911 was called. S3 stated he/she was alerted

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities…shall have all the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff… This requirement is not met as evidenced by: Based on interview staff did not provide care to R1 in a timely manner. On 08/05/24, R1 was recorded screaming for help from 0400 to 0730 hrs. S1 stated R1 waited for hours because “someone is not caring for R1.” S2 stated R1 was possibly waiting for hours to be helped

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needsThis requirement was not met as evidenced by Based on investigation, R8 requires assistance with medication administration. Resident medication M1 was not administered on 7/8/2025. HSD stated "I don't know" regarding the discrepancy, which poses an immediate health, safety and personal rights risk to residents in care.

87465 Incidental Medical and Dental Care(h)(6)(A-F) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...This requirement was not met as evidenced by Based on investigation, R7 to R10, LPAs noted that each resident has medications that were not listed on the Centrally Stored Medication log. HSD stated, "I don't know" regarding the discrepancies, which poses an immediate health, safety and personal rights risk to residents in care.

Ensure hazardous items are locked and not unattended

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above wherein chemicals and hygiene products were observed in 9 out of 11 dementia resident rooms which poses an immediate health, safety, and personal rights risk to persons in care.

Facility personnel sufficiency and competence

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.This facility was found to be deficient as evidenced by a review of the facility forms and documents revealing that a resident required more one on one care and supervision, with redirection, which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited wherein 2 out of 2 side gates in the patio were observed locked using a combination lock which poses an immediate health, safety, and personal rights risk to persons in care.

(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…. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not inform the Department of an incident within seven days of the occurrence of the event which poses an immediate health, safety, and personal rights risk to persons in care.