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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201116
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:15:10 PM


Document Has Been Signed on 10/20/2023 01:15 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
E BAY DELTA AC/SC, 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:140CENSUS: 143DATE:
10/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Melissa Del Dosso, Executive DirectorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10/20/2023 at 12:30 PM Licensing Program Analysts (LPAs) P. Watson and A. Gomez arrived unannounced to conduct a Case Management inspection. LPAs met with Executive Director, Melissa Del Dosso, and explained the purpose of the visit.

While LPAs were conducting another visit in the facility, LPAs were informed of the following deficiency.

-Facility has an approved fire clearance capacity for 140 residents, however the facilities current census is 143.

An immediate civil penalty will be assessed today of $500.


Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.



Exit interview conducted, appeal rights and copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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 10/20/2023 01:15 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
E BAY DELTA AC/SC, 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: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/21/2023
Section Cited
CCR
87202(a)

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87202(a) Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...
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Administrator will submit a capacity increase to CCL by POC date

An immediate $500 civil penalty is being assessed today
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Based on interview, the licensee did not comply with the fire clearance. The facility has an approved fire clearance for a capacity of 140, however the facilities current census is 143 which poses/posed an immediate 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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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