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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200722
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:29:22 PM


Document Has Been Signed on 05/22/2024 02:29 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
E BAY DELTA AC/SC, 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:
05/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tracy Burke, Executive DirectorTIME COMPLETED:
02:40 PM
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On 05/22/2024 at 1:30 PM, Licensing Program Analyst (LPA) Lori Alexander conducted a Health & Safety inspection as a result of a priority 2 complaint. LPA met with Executive Director, Tracy Burke and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 124 degrees F in one of the resident's bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Refrigerator temperature was observed at 36 degrees F. Resident's medications were kept locked in the med room. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 04/15/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

Upon entry to Assisted Living and Memory Care Units, LPA observed residents watching television, working on puzzles, sipping coffee and painting.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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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