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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200722
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:27:33 PM


Document Has Been Signed on 02/15/2024 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 PLEASANTONFACILITY NUMBER:
019200722
ADMINISTRATOR:TRACY BURKEFACILITY TYPE:
740
ADDRESS:5700 PLEASANT HILL RDTELEPHONE:
(925) 416-0238
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:103CENSUS: 86DATE:
02/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Peter Nixdorff, Executive DirectorTIME COMPLETED:
01:45 PM
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On 2/15/2024 at 11:45 AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit to clarify/ gather information upon an incident report that LPA received on 2/14/24. LPA met with Executive Director, Peter Nixdorff and explained the purpose of the visit.

LPA reviewed and obtained R1 unusual incident/injury report leading to R1 injury. LPA interviewed S1, S2, and S3 regrading of the incident that led to R1 incident. LPA obtained and reviewed the after-visit summary from Kaiser regarding the first fall.

R1 had an un-witnessed fall in the common area was sent out to Kaiser. R1 returned the same day with diagnose of Urinary Tract Infection, head injury precaution, and preventing fall. R1 have been closely monitor. R1 haven’t had any history of fall since the leading of the incident.

No deficiencies issued during the visit and a copy of this report is provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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