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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201116
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:35:44 PM


Document Has Been Signed on 03/15/2022 04:35 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 PARK AT SAN RAMONFACILITY NUMBER:
079201116
ADMINISTRATOR:VILLANUEVA, JOSEPHFACILITY TYPE:
740
ADDRESS:9199 FIRCEST LANETELEPHONE:
(949) 744-5200
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:140CENSUS: DATE:
03/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Eugenia Smith, Executive DirectorTIME COMPLETED:
04:50 PM
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On 3/15/22 at 11:55 AM Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a Pre-licensing Inspection. LPA met with Executive Director, Eugenia Smith and explained the purpose of the visit. The facility currently has residents. The facility's fire clearance is approved for 62 ambulatory, 64 non-ambulatory and 14 bedridden residents.

LPA toured facility with Executive Director including but not limited to apartments, bathrooms, kitchen, multiple activity rooms and courtyard. Apartments were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. There is sufficient lighting throughout facility. Hot water temperature was maintained at 117 degrees F in random resident's apartment. First-aid kit was observed to be complete. Smoke detectors are interconnected with sprinklers and observed throughout facility. Carbon monoxide detector was in operating condition Fire extinguisher was last serviced on 6/2/2021.

No issues noted during inspection. LPAs observed that facility is 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.

COMP III was presented to Executive Director.

Exit interview conducted. Due to technical difficulties, a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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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