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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 01/16/2024
Date Signed: 01/16/2024 03:49:05 PM


Document Has Been Signed on 01/16/2024 03:49 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: 77DATE:
01/16/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sarah Dillon, Regional Director of OperationsTIME COMPLETED:
04:00 PM
NARRATIVE
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On 1/16/2023 at 2:00PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Regional Director of Operations, Sara Dillion. Executive Director (ED) Deborah Savoie was not available at the time.

LPA toured facility including but not limited to the resident bedrooms, bathrooms, common area, kitchen, and outdoor area. Facility temperature was maintained at 73 degrees F. 2-day of perishable food supplies were sufficient. Facility order food supplies once a week. Refrigerator was 38 degrees F and freezer was -1 degrees F. Resident's medications were kept locked in the medication room. Smoke detectors are interconnected with sprinkler system. Carbon monoxide detector observe. Fire extinguisher was observed to be full. There are no accessible bodies of water observed.

At 1/16/24 at 2:50PM during the health and safety checked LPA did a random checked of hot water temperature in two residents room in memory care until. Both room temperature were measured at 122.3 and 122.5.

Type A deficiency is cited per Title 22 California Code of Regulations.

Exit interview was conducted with Sara. A copy of this report and Appeal Rights were provided via email to Sara.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/16/2024 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HILLS
FACILITY NUMBER: 019200755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2024
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation. Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F.
-Hot water in resident bathroom sink was measured at 122.3 and 122.5 degrees Farnheit.
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Administrator shall ensure hot water temperature is kept within regulations. Administrator shall adjust hot water temperature to comply with regulation. Written certification required showing regulation has been read and hot water temp has been turned down. Proof of correction to be sent to CCLD by POC date.
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At 1/16/24 at 2:50PM during the health and safety checked LPA did a random checked of hot water temperature in two residents room in memory care until. Both room temperature were measured at 122.3 and 122.5.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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