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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209411
Report Date: 09/06/2024
Date Signed: 09/07/2024 03:48:28 PM


Document Has Been Signed on 09/07/2024 03:48 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:IVY PARK OF MONTEREYFACILITY NUMBER:
277209411
ADMINISTRATOR:SHEARER, KELLIEFACILITY TYPE:
740
ADDRESS:1110 CASS STREETTELEPHONE:
(818) 643-2400
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:112CENSUS: 96DATE:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Business Office Director Lynn TranTIME COMPLETED:
12:00 PM
NARRATIVE
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On 09/06/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a case management inspection. LPA met with Business Office Director Lynn Tran and announced the purpose of the inspection.

The purpose of the inspection was to follow-up on an incident which occurred on 08/15/2024. On 8/15/2024, care provider (CP1) was observed by another care provider (CP2) while assisting with shower and being on the phone using face time video facing resident violating resident personal rights. CP1 was suspended on 08/16/2024 pending investigations. Responsible party of R1 was notified of the incident.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on the attached LIC 809-D. Failure to correct the deficiency may result in civil penalties.
An exit interview was conducted, and a copy of this report provided to the licensee via email. Appeal Rights (LIC 9058) were provided to the licensee.

Exit interview conducted, report signed and copy of this report with appeal rights provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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Document Has Been Signed on 09/07/2024 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: IVY PARK OF MONTEREY
FACILITY NUMBER: 277209411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2024
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal rights. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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The facility implemented staff training including monthly all staff meetings .....
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Based on records review staff/care provider CP1 while providing ADL/shower to R1, had a phone with turned on facetime facing the resident. resident. This poses potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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