306004595-10-18-2024-22-AS-EKIM-DA6VYN-20241018165126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004595
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:51:34 PM

Document Has Been Signed on 10/18/2024 04:51 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK AT FULLERTON		FACILITY NUMBER:	306004595
ADMINISTRATOR:	CHRISTINA HALE		FACILITY TYPE:	740
ADDRESS:	2226 N EUCLID ST		TELEPHONE:	(714) 738-3656
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	85	CENSUS: 51	DATE:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Christina Hale		TIME COMPLETED:	05:00 PM

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On October 18, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Activities Coordinator Richard Bronzellino. Administrator (AD) Christina Hale arrived at the facility around 9:15am. AD Hale said Health Service Director (HSD) Miguel Silva will assist with the visit and can sign the report on their behalf.

The facility is licensed to operate for Eighty-five (85) nonambulatory residents of which fifteen (15) may be bedridden and have a hospice waiver for twenty (20) residents. The facility is a two-story structure and consists of the following: sixty-three (63) resident bedrooms, six (6) offices, sixty-eight (68) bathrooms, living area, two dining areas, TV room, kitchen, bistro, two activity rooms, theater room, lounge, parking garage, and outdoor seating area.

LPA Kim toured inside and outside of the physical plant with AD Hale. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 111, Resident Room 121, Resident Room 151, Resident Room 162, Resident Room 202A, Resident Room 212A, Resident Room 218, Resident Room 240, Resident Room 248A, and Resident Room 263A. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 114.2 degrees F to 118.7 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT FULLERTON	FACILITY NUMBER: 306004595
	VISIT DATE: 10/18/2024

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LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the parking garage. The facility has fourteen (14) fire extinguishers that were charged, mounted throughout the facility, and serviced on October 17, 2024.

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were inspected by Johnson Controls on April 30, 2024, and are inspected semiannually. Sprinkler system was inspected, and tested by State of California, State Fire Marshall on September 11, 2024. A working telephone (714-738-3656) and an internet capable devices for teleconferencing purposes remains available. LPA observed the facility had a current Evidence of Liability Insurance.

LPA Kim conducted an audit of seven (7) resident files (R1-R7), eight (8) staff files (S1-S8), and medication and medication administration record were all in order and complete. LPA Kim conducted four (4) staff interviews and two (2) resident interviews.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to Health Service Director Miguel Silva.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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