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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201116
Report Date: 04/12/2023
Date Signed: 04/12/2023 11:16:17 AM

Document Has Been Signed on 04/12/2023 11:16 AM - 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 AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:SMITH, EUGENIAFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 140CENSUS: 118DATE:
04/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Melissa Malek, Regional Director of Health ServicesTIME COMPLETED:
11:25 AM
NARRATIVE
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On 4/12/23 at 10:10 AM, Licensing Program Analyst (LPA) conducted a Case Management as a result of complaint #15-AS-20221104082159. LPA met with Melissa Malek, Regional Director of Health Services.

Based on record review and information obtained, a smoke from a heating and air conditioning unit triggered the smoke alarm detector in R1's apartment. During record review and interview with W1 on 11/10/22, it was revealed that the smoke detectors in rooms are currently not being monitored by the fire alarm company.

On 11/11/22, LPA obtained a copy of Fire & Life Inspection report and LPA observed facility was cleared by Fire Marshall on 11/10/22.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided Melissa Malek, Regional Director of Health Services.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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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Document Has Been Signed on 04/12/2023 11:16 AM - It Cannot Be Edited


Created By: Lizette Francisco On 04/12/2023 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT SAN RAMON
FACILITY NUMBER: 079201116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited

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87203 FIRE SAFETY
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Based on record review and interview, Licensee did not comply with the regulation cited above by not having smoke detectors monitored by fire alarm company which poses a potential health and safety risk to residents 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 Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
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