<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601177
Report Date: 10/07/2025
Date Signed: 10/07/2025 12:04:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2025 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250529111732
FACILITY NAME:IVY PARK OF BELMONTFACILITY NUMBER:
415601177
ADMINISTRATOR:MINNIE WEBERFACILITY TYPE:
740
ADDRESS:1010 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 508-0400
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:117CENSUS: 76DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Anne BuerhausTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to report incidents and death to CCLD
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 7, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit.

Regarding the allegation facility failed to report incidents and death to CCLD, according to the reporting party, they are unsure if CCLD was notified regarding Resident 1's (R1's) falls and if CCLD was notified regarding R1's death.

During the investigation, LPA interviewed staff and reviewed facility's and Department's records. Based on Department's records, although the facility reported R1's death, the facility failed to report R1's falls to CCLD.

According to records reviewed, although the facility submitted a death report for R1 to CCLD, the facility did not submit any incident reports to CCLD in regarding to R1. According to staff interviewed and records reviewed, there were internal facility reports regarding R1's falls and hospice and responsible party were notified, however staff indicated that there were at least two instances where hospice ordered hospitalization related to a fall. These falls were not reported to CCLD. (Continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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 14-AS-20250529111732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IVY PARK OF BELMONT
FACILITY NUMBER: 415601177
VISIT DATE: 10/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed the Department's documents, although, a death report was submitted to CCLD, no incident reports were submitted to CCLD in regards to R1's falls, and the facility was unable to provide fax confirmation sheets to show that incident reports were submitted to CCLD.

Based on the interviews conducted, records reviewed and information collected, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator, Anne Buerhaus and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2025 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250529111732

FACILITY NAME:IVY PARK OF BELMONTFACILITY NUMBER:
415601177
ADMINISTRATOR:MINNIE WEBERFACILITY TYPE:
740
ADDRESS:1010 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 508-0400
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:117CENSUS: 76DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Anne Buerhaus, TIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have sufficient amount of staff
Facility did not adequately address a change in resident's condition
Medication was not administered as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 7, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit.

Regarding the allegation, facility does not have sufficient amount of staff, according to the reporting party, there were several occasions, Resident 1 (R1) would need assistance to go to the bathroom during lunch and begin shaking for holding it in. Reporting party indicating, caregivers would be called for assistance to take R1 to the bathroom, however, however caregivers would say to wait until after lunch because they did not have the staff to take R1 to the bathroom.

During the investigation, LPA reviewed staff roster, interviewed staff and interviewed residents. Based on 5/5 staff interviewed, there is sufficient staffing to meet the residents needs at the facility. According to 5 residents interviewed, there were conflicting information provided.

Regarding the allegation, facility did not adequately a change in resident's condition, according to the reporting party, R1 had 3 falls causing injuries due to falling off his/her bed and the facility did not reassess the R1. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20250529111732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IVY PARK OF BELMONT
FACILITY NUMBER: 415601177
VISIT DATE: 10/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the investigation, LPA reviewed R1's file, interviewed staff, and interviewed hospice notes. According to staff interviewed and documents reviewed, R1 had 8 falls within 8 months, and the facility implemented frequent checks that were being conducted every 1-2 hours, in addition to close supervision by bringing R1 into the common area. The facility also removed all fall hazards from R1's room and placed a fall mat in R1's room. Based on R1's file, after each fall, the facility would reach out to hospice and R1's physician for medication adjustments.

Regarding the allegation, medication was not administered as prescribed, according to the reporting party, R1 was experiencing anxiety and agitation and was prescribed morphine on an as needed basis to control this condition. Reporting party indicated that the facility was not administering the morphine when R1 needed it.

During the course of the investigation, LPA conducted interviews, conducted research, and reviewed pertinent documents related to the allegation. According to interviews and documentation reviewed, there are two Registered Nurses (RNs) and one Licensed Vocational Nurse (LVN) at the facility who were able to provide morphine to R1 as needed as prescribed by the physician, however based on interviews conducted, R1 did not require morphine until he/she was transitioning to hospice and that's when morphine was being prescribed by hospice. In addition, staff interviews indicated that morphine was on standby.

Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20250529111732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: IVY PARK OF BELMONT
FACILITY NUMBER: 415601177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2025
Section Cited
CCR
87211(a)(1)
1
2
3
4
5
6
7
87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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...

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/administrator shall review CCR 87211 and submit acknowledgment to ensure compliance with the regulation.
8
9
10
11
12
13
14
Based on interviews conducted and records reviewed, R1 had falls that resulted in hospitalization, however the facility failed to submit an incident report to CCLD which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5