198603715-9-17-2024-28-AS-NGAA-D97RXM-20240917132457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603715
Report Date: 09/17/2024
Date Signed: 09/17/2024 01:25:05 PM

Document Has Been Signed on 09/17/2024 01:25 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 SAN MARINO		FACILITY NUMBER:	198603715
ADMINISTRATOR:	SANCHEZ, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	8332 HUNTINGTON DRIVE		TELEPHONE:	(626) 292-7800
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	74	CENSUS: 56	DATE:	09/17/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	KImberly Sanchez, Executive Director		TIME COMPLETED:	01:30 PM

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Licensing Program Analysts (LPAs) Galarza & Mayra Cota conducted an announced visit to the facility for the purpose of a Pre-licensing evaluation. LPA met with Executive Director Kimberly Sanchez.

An application was submitted to CCLD on 9/29/2023 for a Change of Ownership for a Residential Care Facility for the Elderly for ages 60 years and older. The fire clearance has been approved for a capacity of 74 residents, which 70 may be non-ambulatory and 4 may be bedridden. A hospice waiver for 15 residents has been approved. The facility has a Dementia unit of 19 residents. There are currently 56 residents residing at the facility and 8 are receiving hospice care.

Physical Plant:

The facility is two 2-story building consisting of a Memory Care unit "Evergreen", 52 resident rooms, 2 activity rooms, 2 dining rooms, kitchen, dining room, 2 bathique rooms, 2 TV rooms, Library, Bistro room, hair salon, administration offices, laundry rooms, storage areas, 2nd floor terrace area, courtyard patio area, electrical rooms, and parking garage. The passageways and walkaways are free from obstructions. The outdoor areas are free of debris/hazards. There is a water fountain in the 1st floor patio area. Residents may have pets.

Observations: There are two (2) evacuation chairs in the stairways to be used during an emergency as a path of egress from the facility to safety. The facility does not have surveillance video cameras in place. The two (2) bathique rooms have inoperable bathiques. The 2nd floor bathique room is presently used as a storage room. Per, Executive Director the bathique rooms will be converted to a different use in the near future.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SAN MARINO	FACILITY NUMBER: 198603715
	VISIT DATE: 09/17/2024

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Signal System: The signal system was tested and is operational.

Fire Inspection: On 5/1/2024 an annual fire inspection was conducted. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The last fire drill was conducted on 8/28/2024.

Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways Battery operated carbon monoxide detectors were observed in hallways.

Appliances: Refrigerators, Stove burners, Oven, Freezers, Washer and Dryer are all working properly.

Bedrooms: There shall be no more than two clients per bedroom. Bedrooms are equipped with a bed, night-stand, overhead lighting, and closet space.

Staff bedrooms: No rooms are designated for live-in staff.

Bathrooms: All bathrooms have a working toilet, wash basin, and bathtub/shower. Each floor has public restrooms. Public restrooms have an operable call light system.

Linen and Hygiene Supplies: Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bed spreads. Adequate supply of linens, hygiene supplies, and Personal Protective Equipment (PPEs) are in place.

Emergency Phone numbers, exit plan and menu: Posted and readily available for review in the hallway of first floor. All fire extinguishers are fully charged.

Toxins:
All are stored and locked in supply rooms, locked cabinets, and outdoor storage areas.

Water Temperature: The hot water temperature tested between 105-120 degrees Fahrenheit which meets Title 22 regulations.

First Aid Kit and Book: A first aid kit was inspected, which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. Facility does not have a First Aid Manual.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SAN MARINO	FACILITY NUMBER: 198603715
	VISIT DATE: 09/17/2024

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Food Service: Dishes and cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen and only accessible for staff. Food supply is stored in the kitchen and consists of following: 2 days perishable food and 7 days non-perishable food. The freezer was maintained at 0 degrees F and the refrigerator was at 40 degrees F. Food in refrigerators were properly covered to avoid contamination. Dishes, cups and flat ware are stored in the kitchen area.

Staff and Residents files: Staff and Residents files are stored and maintained at the facility. Centrally Stored Medication and Destruction Records were reviewed. Facility does not handle cash resources of residents. A surety bond is not in place. Administrator certificate expires 8/5/2025.

Liability Insurance: One million dollars ($1,000,000) per occurrence and three million ($3,000,000) in the total annual dollars aggregate.

Fire clearance: Granted on 7/10/2024 for 70 non-ambulatory and 4 bedridden residents. Delayed egress is in place in the 2nd floor Dementia "Evergreen" unit.

Component III: Component III was waived.

The are no items of correction needed.

An exit interview was conducted with Administrator Kimberly Sanchez. Due to printing issues a copy of the report will be emailed and mailed. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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