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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200754
Report Date: 10/02/2023
Date Signed: 10/02/2023 02:54:52 PM


Document Has Been Signed on 10/02/2023 02:54 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 WALNUT CREEKFACILITY NUMBER:
079200754
ADMINISTRATOR:IRYN MACAMAYFACILITY TYPE:
740
ADDRESS:2175 YGNACIO VALLEY RDTELEPHONE:
(925) 932-3500
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:86CENSUS: 67DATE:
10/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eugenia SmithTIME COMPLETED:
03:30 PM
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On 10/02/2023 at 02:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a Case Management visit concerning a COVID-19 outbreak at the facility. The LPA stated the purpose of the visit to Regional Operations Specialist (ROS) Eugenia Smith.

The LPA and ROS discussed the reporting of the outbreak by staff members. The facility staff followed the reporting requirements from PIN 23-04-CCLD.

No citations issued during the visit.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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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