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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602882
Report Date: 11/09/2023
Date Signed: 11/09/2023 10:30:49 AM


Document Has Been Signed on 11/09/2023 10:30 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:IVY PARK AT CLAREMONTFACILITY NUMBER:
198602882
ADMINISTRATOR:HERNANDEZ, DAISYFACILITY TYPE:
740
ADDRESS:2053 N TOWNE AVETELEPHONE:
(909) 398-4688
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:81CENSUS: 47DATE:
11/09/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Administrator, Daisy HernandezTIME COMPLETED:
10:29 AM
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Licensing Program Analyst (LPA) Alberto Lopez and Investigative Branch Investigator Jose Santana conducted an unannounced Plan of Correction Visit (POC) to follow up on the citation issued on 11/03/2023. The purpose of this visit is to follow up the POC that was due on 11/07/23. Upon arriving at the facility, LPA met with Administrator, Daisy Hernandez and explained the purpose of this visit.

On 11/03/23 LPA Lopez conducted a case management visit, and the following citation was cited on 11/03/23:

87755(c) Resident Records: The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed, if necessary, for copying. On today's POC visit, the records requested were not provided, POC was not corrected. Civil penalty assessed.

Exit Interview conducted and copy of the report and appeal rights was provided to the Administrator, Daisy Hernandez
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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