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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202849
Report Date: 03/30/2022
Date Signed: 05/04/2022 03:56:34 PM


Document Has Been Signed on 05/04/2022 03:56 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:IVY PARK AT SALINASFACILITY NUMBER:
275202849
ADMINISTRATOR:SAULNIER, AMYFACILITY TYPE:
740
ADDRESS:1320 PADRE DRIVETELEPHONE:
(831) 754-5532
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:185CENSUS: 150DATE:
03/30/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Amy Saulnier, AdministratorTIME COMPLETED:
12:15 PM
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On 03/30/22, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing / Component III Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Administrator Amy Saulnier, Administrator. The facility is a 167 bedrooms of which 123 bedrooms is in assisted living and 44 bedrooms is in memory care. Fire clearance is granted by the local Fire Department for 167 non-ambulatory and 18 bedridden for total capacity of 185.

LPA conducted a tour inside and outside of the facility. The following areas were toured and inspected:

1st Floor: Community space, Administration offices, Front Lobby, Mail Room, Fitness Center, Laundry Room, Private Dining Room, Dining Area, Medication Room, Kitchen, Break room, Lounge room, Activity rooms, and a sample of rooms.

2nd Floor: Administration offices, Hair Salon, Laundry Room, Break room, Lounge room, Medication Room, Library, Chapel, a sample of rooms.

3rd Floor: Laundry Room, a sample of rooms.

LPA observed bathrooms to be functioning properly with grab bars and non-skid mats. Food supply was checked and appeared to be an adequate supply. Emergency exits are posted. A fire extinguisher was observed and has a service date of 05/26/21. Medications were kept locked and inaccessible to residents in care. Resident records were reviewed. LPA observed resident Admission Agreements and Physician Reports. A sample of staff records were reviewed to have a criminal record clearance.

Component III was conducted during today's pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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