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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 01:01:17 PM

Document Has Been Signed on 08/19/2024 01:01 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/
DIRECTOR:		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 VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Regional Operations Specialist, Pari Manouchehri TIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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On 8/19/2024 at 12:00pm Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit as a result of an Unusual Incident Report received 8/09/2024. 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.

On 9/9/2024 the department received an unusual incident report that stated "Resident (R1) was climbing walls outside the community and entering neighboring homes. (R1) was not responding to staff while running into the street. (R1) was jumping on parked cars; jumped into a car and was flipping off staff and passersby. Resident had just moved in less than 24 hours prior and had a clear 602, assessment and smooth move in. (R1's) behaviors were a direct contradiction to the totality of information gathered prior to move in."

LPA reviewed R1's 602 (Physicians report). The 602 stated that R1 could leave unassisted and R1 was independent. R1 did not sustain any injuries. R1 has since been diagnosed with unspecified Schizophrenia and no longer resides at the facility. On 8/3/2024 and 8/6/2024 the facility retrained staff on elopement procedures.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
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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