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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200754
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:52:20 PM


Document Has Been Signed on 03/27/2024 04:52 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:CASTRO, GILBERT MFACILITY TYPE:
740
ADDRESS:2175 YGNACIO VALLEY RDTELEPHONE:
(925) 932-3500
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:86CENSUS: 62DATE:
03/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH: Executive Director Gilbert CastroTIME COMPLETED:
05:00 PM
NARRATIVE
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On 3/27/2024, during an unannounced change of ownership prelicensing visit for Ivy Park at Walnut Creek license number 079201317, Licensing Program Analyst (LPA) J. Sampair cited this facility for a deficiency during a tour of the facility with Executive Director (ED) Gilbert Castro.

Details of the deficiency are in the LIC 809-D, which was cleared during the inspection.

Exit interview conducted and a copy of this report provided via email to the ED.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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 03/27/2024 04:52 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: IVY PARK AT WALNUT CREEK
FACILITY NUMBER: 079200754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
87705(h)

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87705 Care of Persons with Dementia (h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches ... to protect the safety of residents.

This requirement is not met as evidenced by:
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The Licensee repaired the gate during the inspection.
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Based on observation, the licensee did not comply with this section, because 1 of the 2 gates for the outdoor space for memory care residents was not self-closing, which poses a potential health, safety or personal rights risk to persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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