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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 12/26/2023
Date Signed: 12/26/2023 02:31:09 PM


Document Has Been Signed on 12/26/2023 02:31 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 OAKLAND HILLSFACILITY NUMBER:
019200755
ADMINISTRATOR:CAGULADA, DILLON RFACILITY TYPE:
740
ADDRESS:11889 SKYLINE BLVDTELEPHONE:
(510) 531-7190
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:100CENSUS: 75DATE:
12/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eric Browne, Health Services DirectorTIME COMPLETED:
02:45 PM
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On 12/26/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding R1 incident that happened on 12/17/23. During the un-witness incident R1 bit a gel ice pack and was sent to the ER for evaluation. LPA spoke with Eric Browne, Health Services Director and explained the purpose of the visit.

LPA interviewed staff (S1) regarding resident (R1) care prior to the incident. LPA obtained progress notes/ care notes, and the after-visit summary after R1 was admitted to the hospital. After reviewing the documents R1 was sent back to the community with additional supervision from the facility, and daily check up to monitor R1 condition after the incident.

No deficiencies cited. 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: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
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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