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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200722
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:32:27 PM


Document Has Been Signed on 10/27/2023 04:32 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: 88DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Tracy Burke, Executive DirectorTIME COMPLETED:
04:40 PM
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On 10/27/2023 at 10:10 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Tracy Burke and explained the purpose of the visit. The facility’s fire clearance was approved for 06/28/2023.

At around 12 pm, LPA inspected the facility including but not limited to resident apartments, bathrooms, dining rooms, common living areas, kitchen, and outside areas. The room temperature and lighting were adequate for the safety and comfort of the residents. Rooms were furnished appropriately and observed to be clean and in good repair. All rooms have private bathrooms and showers which were equipped with grab bars and safety/nonskid floors/mats. There was an adequate supply of 2 day perishable and 7 day non-perishable foods. Refrigerator temperature is measured at 35 degrees Fahrenheit. Freezer temperature was measured at -10 degrees Fahrenheit. Kitchen and food preparation areas were observed to be clean and in compliance. There were no bodies of water or fire safety hazards observed. All indoor and outdoor passageways were kept free of obstruction. Facility is equipped with interconnected smoke detectors, sprinklers, and fire alarm. Memory Care Unit doors were equipped with delayed egress. Fire extinguishers throughout facility were fully charged and last inspected on 10/1/2023. Last Fire/Earthquake Emergency drill was conducted on 7/1/23. The facility's fire clearance is approved for 103 residents (all of which may be non-ambulatory and 20 bedridden). The facility has a written emergency disaster plan posted dated 7/1/23. Administrator is on site at least 40 hours a week to oversee the business operation. There is an adequate number of trained staff to meet residents' needs during inspection. Staff assisting with activities of daily living and medications had the necessary training. LPA observed hot water temperature measured in residents apartments measured at 110 degree Fahrenheit.



LPA reviewed 10 residents’ records and reviewed 10 staff records and 10 of 10 have current first aid training and associated to the facility. LPA reviewed 10 resident files and review resident’s stored medications, and Medication records. LPA observed centrally stored medications were locked and inaccessible to residents.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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