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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201506
Report Date: 05/05/2025
Date Signed: 05/05/2025 03:48:10 PM

Document Has Been Signed on 05/05/2025 03:48 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 AT BERKELEY, THEFACILITY NUMBER:
019201506
ADMINISTRATOR/
DIRECTOR:		STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:2000 DWIGHT WAYTELEPHONE:
(510) 900-8959
CITY:BERKELEYSTATE: CAZIP CODE:
94704
CAPACITY: 138CENSUS: 0DATE:
05/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Angeles Sticka, Executive Director TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 05/5/2025 around 9:30 AM, Licensing Program Analysts (LPA) L. Holmes arrived unannounced to conduct a Pre-licensing Inspection. Upon arrival, LPA was greeted and met with Angeles Sticka, Executive Director (ED) and Andrew Moret, VP of Operations. The facility is approved for a capacity of 138.

The facility has a secured, keyless entry at the entrance with a concierge station, bistro, and common area. LPA, VP of Operations, and ED toured facility and met with the Director of Wellness where the first aid kit was complete; medication and residents' electronic and paper files will stored and locked in Wellness unit also. The facility consists of six (6) floors, the 2nd floor is dedicated to Memory Care (MC), and the lower level has the Emergency Evacuation plans in place per designated zones. Throughout the facility are activity calendars, game rooms, terraces, courtyards, individual apartments, staff offices, and a parking structure. The apartments are equipped with proper furnishings, adequate lighting, grab bars and non skid surfaces. The model room's temperature was maintained at 70 degrees F. and the hot water temperature was measured at 110.5 degrees F; routine maintenance checks are performed daily. There is a sufficient supply of 7-day non-perishable and 2-day supply of perishable foods. Smoke detectors and carbon monoxide units were operational during visit and are monitored by the Fire Department. Fire extinguisher was last serviced on 03/24/25. Component III was reviewed and completed with ED, and VP of Operations.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 AT BERKELEY, THE
FACILITY NUMBER: 019201506
VISIT DATE: 05/05/2025
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 ...continude fron LIC809.

CORRECTIONS OBSERVED:
-The numeric address of the building's facade is 2501 Milvia St. Prior to Operation, visible signage for the address on record will be present.
-All staff need to be associated to the facility prior to working at the facility
-STD850 to be confirmed/updated by the City of Berkeley's Fire Marshall
- Central Applications Unit (CAU) to update comments on on the license

LPA observed that the facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided to Andrew Badoud, Executive Director.

NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
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