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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 09/24/2024
Date Signed: 09/24/2024 10:57:23 AM


Document Has Been Signed on 09/24/2024 10:57 AM - 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: 135DATE:
09/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Laura RodriguezTIME COMPLETED:
10:12 AM
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On 9/24/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management visit to follow up on the incident report submitted by the licensee dated 09/16/2024 regarding a staff and a resident. LPA met with Laura Rodriguez, Executive Director and explained the reason for the visit.

During the visit, LPA interviewed the Executive Director, Resident #1 (R1) and R1’s responsible party. LPA also obtained copy of residents' census and staff roster. LPA was also informed that Staff #1 was terminated due to the staff #1 actions that did not follow company protocols. The facility has plans of conducting in-service training for current staff.

No deficiencies cited during today's visit. 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: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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