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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 08/12/2024
Date Signed: 08/12/2024 03:13:50 PM


Document Has Been Signed on 08/12/2024 03:13 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:IVY PARK AT CERRITOSFACILITY NUMBER:
198602608
ADMINISTRATOR:LAURA RODRIGUEZFACILITY TYPE:
740
ADDRESS:11000 NEW FALCON WAYTELEPHONE:
(562) 865-9500
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:163CENSUS: DATE:
08/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Executive Director Laura RodriguezTIME COMPLETED:
03:28 PM
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On 8/12/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management visit to follow up on the incident report and SOC 341 submitted by the Executive Director(ED) Laura Rodriguez dated 8/2/2024, regarding a resident and resident altercation. During the visit, LPA interviewed the Executive Director.

According to SOC 341 and Incident report, it is alleged that on 8/02/2024, R1 exhibited aggressive behavior towards R2 and R3. R1 tried to sit on the couch between R2 and R3. R2 and R3 tried to tell R1 to hold on so they can make some space. R1 then proceeded grabbed R2 by the arm and let a scratch. Staff was contacted and helped R1 to the room. The ambulance or police was not contacted for the incident. Per ED R1 was had a move out date prior to the incident and the family has opted to move R1 to facility requiring a higher level of care. The facility stated there are no issues at this time.

Additional follow up may follow. Executive Director Laura Rodriguez was advised, and a copy of this report was given.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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