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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201329
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:05:29 PM


Document Has Been Signed on 08/16/2024 03:05 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 OF OAKLAND HILLSFACILITY NUMBER:
019201329
ADMINISTRATOR:HARRELL, YOLANDAFACILITY TYPE:
740
ADDRESS:11889 SKYLINE BOULEVARDTELEPHONE:
(510) 531-7190
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:100CENSUS: 60DATE:
08/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Yolanda HarrellTIME COMPLETED:
02:00 PM
NARRATIVE
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On this day at around 10 am, Licensing Program Analysts (LPAs) Luisa Fontanilla and Ardalan Gharachorloo arrived at the facility unannounced to conduct pre licensing inspection and met with Executive Director (ED) Yolanda Harrell. LPAs explained to Harrell the purpose of the visit. This pre licensing is being conducted due to a change in ownership (CHOW) of the facility.

The facility has an approved fire clearance for 96 non ambulatory and 4 bedridden residents. LPAs 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.

Hot water temperature was measured in five resident rooms at 106 Fahrenheit. There was sufficient supply of perishable and non perishable foods. Multiple fire extinguishers that appeared full and were last serviced on 12/7/2023 were observed. The facility's fire clearance was approved on 1/22/2024. Last fire drill was conducted on 7/18/2024.

During the resident file review, LPAs observed Resident 2 (R2) Physician's Report does not have the physician's signature. R2 is diagnosed with Dementia. R3's Physician's Report does not have TB test. R3 is diagnosed with Dementia.

The ED will have R2 and R3 Physician's Reports completed and send a copy to CCL by

The facility is not yet licensed. LPAs will notify CAB about the visit.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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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Document Has Been Signed on 08/16/2024 03:05 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 OF OAKLAND HILLS
FACILITY NUMBER: 019201329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review conducted, the licensee did not comply with the section cited above in not having R2's Physician's Report signed by the doctor and R3 without TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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By POC date, updated Physician's Reports for R2 and R3 will be completed and submitted to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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