<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201317
Report Date: 03/07/2025
Date Signed: 03/07/2025 05:08:43 PM

Document Has Been Signed on 03/07/2025 05:08 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/
DIRECTOR:		LINDA NGUYENFACILITY TYPE:
740
ADDRESS:2175 YGNACIO VALLEY ROADTELEPHONE:
(925) 932-3500
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 86CENSUS: 71DATE:
03/07/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Executive Director Linda NguyenTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On March 7, 2025 at 1:15 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this post licensing inspection. The LPA informed Executive Director (ED) Linda Nguyen of the purpose for this visit.

The LPA inspected the inside and outside of the facility. The inspection included the kitchen, dining area, common areas, bedrooms, and yard outside common areas. An adequate amount of food supplies were observed, more than the required minimum of 2 days of perishable and 7 days of non-perishable food. The central storage for medications was locked. The cleaning supplies and dangerous objects were stored in locked cabinets.

The Facility has working smoke and carbon monoxide detectors. The staff of the facility conduct disaster / emergency and fire drills on a quarterly basis; records showed that the most recent drill was conducted on November 27, 2024. The fire extinguishers were all replaced on January 16, 2025. The indoor temperature was 76.8 degrees Fahrenheit, within the acceptable range. The maximum hot water temperature was 113.3 degrees Fahrenheit.

The LPA reviewed 5 resident and 5 staff records.

1 Type-A citation and a civil penalty for $500 were issued during this inspection. Refer to LIC 809-D and LIC 421BG for details.

Exit interview conducted and a copy of this report and the Appeals provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/07/2025 05:08 PM - It Cannot Be Edited


Created By: James Sampair On 03/07/2025 at 04:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IVY PARK AT WALNUT CREEK
FACILITY NUMBER: 079201317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 of 5 records reviewed not associated with the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2025
Plan of Correction
1
2
3
4
Corrected during inspection.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2