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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 01/27/2026
Date Signed: 01/27/2026 05:11:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250709140228
FACILITY NAME:IVY PARK AT HAYWARDFACILITY NUMBER:
019200922
ADMINISTRATOR:NAENSILA RANDHAWAFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:170CENSUS: 113DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Joseph Villanueva/Executive DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff do not answer residents calls for assistance timely.
INVESTIGATION FINDINGS:
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On this day, January 27, 2026, 1t 12:10 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and close the complaint. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit.

During the course of investigation, LPA obtained copies of residents rosters and staff schedule. LPA reviewed residents' records and obtained copies of including but not limited to the following documents: Admission Agreement; LIC602 A Physician's Repors; Residents' Assessments/Care Plan. LPA interviewed 5 residents and staff on July 17, 2025, January 7, 2026 and January 27, 2026.


.....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20250709140228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: IVY PARK AT HAYWARD
FACILITY NUMBER: 019200922
VISIT DATE: 01/27/2026
NARRATIVE
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Two of the residents stated there were times when they pressed their call button and it takes time for the staff to respond. One of these residents stated when his Home Health nurse pressed the call button for assistance to change his clothes, the nurse end up changing and took 30 minutes for the caregiver to respond and at that time he was already in the dining room.

On January 7, 2026, resident (R5) pressed the call button and the caregiver assigned did not respond. LPA interviewed the assigned caregiver who stated she was assisting another resident at the time R5 called for assistance and she didn't attend to R5 nor called her partner caregiver to check R5.

On January 27, 2026, one of the staff interviewed stated seeing reports where resident fell at night and no caregiver responded.

Based on information gathered, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan of correction were discussed with ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250709140228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT HAYWARD
FACILITY NUMBER: 019200922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/10/2026
Section Cited
HSC
1569.269(a)(6)
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ยง1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers,
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Executive Director to in-service the staff and submit copy of training topics with attendees signatures by 2/10/26.
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qualifications, and competency to meet their needs.
-This requirement is not met as evidenced by:
-Based on records review and interviews, the licensee did not comply with the section when staff did not respond to residents' call timely which posed a potential health, safety and/or personal right risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250709140228

FACILITY NAME:IVY PARK AT HAYWARDFACILITY NUMBER:
019200922
ADMINISTRATOR:NAENSILA RANDHAWAFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:170CENSUS: 113DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Joseph Villanueva/Executive DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Due to lack of staff, residents have had multiple falls.
Staff do not check on residents every 2 hours.
INVESTIGATION FINDINGS:
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On this day, January 27, 2026, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and close the complaint. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit.

During the course of investigation, LPA obtained copies of residents rosters and staff schedule. LPA reviewed residents' records and obtained copies of including but not limited to the following documents: Admission Agreement; LIC602 A Physician's Repors; Residents' Assessments/Care Plan. LPA also reviewed Unsual Incident Reports and facilty notes. LPA interviewed 4 residents and staff on July 17, 2025, January 7, 2026 and January 27, 2026.


.....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250709140228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: IVY PARK AT HAYWARD
FACILITY NUMBER: 019200922
VISIT DATE: 01/27/2026
NARRATIVE
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Allegation: Due to lack of staff, residents have had multiple falls.
Unusual Incident Reports submitted by the facility from July 2025 to January 20, 2026 pertaining to fall incidents were reviewed of which showed mostly were un-witnessed. All the staff interviewed stated they don't feel there's staffing issues. One of these staff stated staffing is good but more is better. Five residents interviewed stated they don't feel staffing is an issue. Therefore, the allegation is unsubstantiated.

Allegation: Staff do not check on residents every 2 hours.
Two of the staff stated residents in Memory Care are on two hour check throughout the day. Another staff stated the care providers are not required to check the residents in Assisted Living every 2 hours, and that the 2 hours checking is based on situation and should be on the Care Plan. All residents interviewed including one whose spouse is also In Memory Care stated they are not on every 2 hour check. Therefore, the allegation is unsubstantiated.

Based on interviews and records reviews, the allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5