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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201116
Report Date: 08/19/2024
Date Signed: 08/19/2024 01:36:01 PM


Document Has Been Signed on 08/19/2024 01:36 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 SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:COONS, JENNIFER SFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:162CENSUS: 140DATE:
08/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Regional Operations Specialist, Pari ManouchehriTIME COMPLETED:
01:45 PM
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On 8/19/2024 at 1:05pm Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit as a result of an Unusual Incident Report received 7/22/2024. LPA met with Regional Operations Specialist, Pari Manouchehri and Health Service Director, Anlisse Ramirez and explained the purpose of the visit. The current census is 140.

It was reported that on 7/16/2024 R1 had their purse, phone, wallet and its contents stolen by S1. LPA obtained S1's personnel file for review. S1 has since been terminated. R1 did not wish to be interviewed. R1 left their personal belongings in the dining area where S1 took them when no one was around. LPA will return at a later date to conduct another case management visit. Facility retrained staff on reporting requirements and procedures on what to do when finding items at the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
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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