<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201324
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:20:08 PM


Document Has Been Signed on 08/22/2024 02:20 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:IVY PARK AT PLEASANTONFACILITY NUMBER:
019201324
ADMINISTRATOR:MARTINEZ, DIANE DIEMFACILITY TYPE:
740
ADDRESS:5700 PLEASANT HILL ROADTELEPHONE:
(925) 416-0238
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:103CENSUS: 83DATE:
08/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Gibert Castro, Executive DirectorTIME COMPLETED:
02:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/22/2024 at 10:25 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct pre-licensing inspection. LPA explained to Gilbert Castro, Executive Director the purpose of the visit. This pre licensing is being conducted due to a change in ownership (CHOW) of the facility.

LPA inspected the facility inside and out including but not limited to the assisted living and Memory Care units, common areas, kitchen, dining and activity room. LPA also inspected the facility including but not limited to 3 resident rooms, bathrooms, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed. There is sufficient lighting throughout facility.

Room temperature was maintained at 72 degrees F and hot water temperature was maintained at 106 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 11/16/2023.

LPA reviewed 5 staff files and 6 residents files and all were complete.

No issues noted during inspection. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan GharachorlooTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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 1