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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201317
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:53:41 PM


Document Has Been Signed on 03/27/2024 04:53 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 WALNUT CREEKFACILITY NUMBER:
079201317
ADMINISTRATOR:CASTRO, GILBERTFACILITY TYPE:
740
ADDRESS:2175 YGNACIO VALLEY ROADTELEPHONE:
(925) 932-3500
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:86CENSUS: 62DATE:
03/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH: Executive Director Gilbert CastroTIME COMPLETED:
05:00 PM
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On 3/27/2024, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a change of ownership prelicensing visit. Upon entry into the facility, the LPA informed Executive Director (ED) Gilbert Castro of the purpose of the visit.

LPA toured the facility inside out with the ED. The LPA inspected the kitchen, dining areas, restrooms, community living spaces, bedrooms, bathrooms, trash areas, and the exterior of the facility. The facility was appropriately furnished and well lit. Professional grade equipment was installed and maintained for resident care. Food supplies were checked and observed to be sufficient and new orders come on a regular basis. No swimming pool or other body of water was on the facility grounds. Medications are centrally stored. Bathrooms and showers were observed equipped with grab bars and non-skid mats. Carbon monoxide and smoke detectors operational. First aid kit inspected. Fire extinguishers were serviced 1/31/2024. Facility has emergency lighting. Hot water temperature in one of the common areas was tested and measured at 115.9 degrees Fahrenheit at 3:14 PM. Complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council and Rights to Family Council were observed posted in a prominent place.

Facility passed pre-licensing inspection and Component III training provided for ED Castro. Final review of application and license to be granted by Central Applications Bureau analyst.

Exit interview conducted and copy of this report provided via email to ED Castro.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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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