306006069-2-23-2022-22-AS-MRED-CBWS5G-20220223123418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006069
Report Date: 02/23/2022
Date Signed: 02/23/2022 12:34:32 PM

Document Has Been Signed on 02/23/2022 12:34 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK AT BRADFORD		FACILITY NUMBER:	306006069
ADMINISTRATOR:	CALABRESE, ROSE		FACILITY TYPE:	740
ADDRESS:	1180 N BRADFORD AVE		TELEPHONE:	(714) 996-9292
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	136	CENSUS: 80	DATE:	02/23/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Rose Calabrese		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michelle Reed arrived at the facility for the purpose of conducting a Pre-Licensing visit. Upon arrival, LPA met with Administrator Rose Calabrese. Due to COVID protocols, LPA's temperature was taken upon entry and a sign in sheet was available. LPA also observed hand sanitizing stations. Staff were also seen wearing masks. An initial application for a Change of Ownership was submitted to the Central Applications Bureau (CAB) on 8/24/21 for a capacity of 136- non ambulatory residents of which 21 may be bedridden. LPA Reed conducted a tour of the facility inside and out with Rose Calabrese at approximately 10:30 am and observed the following: Structure: The facility consists of two separate buildings, Assisted Living and a Dementia Unit. A Fire Clearance was granted on 12/15/21 for a total of 136 residents. 115 non ambulatory and 21 bedridden. Bedridden on first floor only, maximum of (2) per room), in addition, facility is approved for delayed egress for the Dementia building which is referred to as Evergreen. Living Room/ Dining Room: Adequate seating is available in the dining room and living room as well as the activities room. There is also a dining room and living room in the locked memory care unit. Bedrooms: Resident bedrooms toured were equipped with appropriate lighting, chair, night stand and ample closet space. A call system was in place for resident rooms. Bathrooms: Resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars. Water temperature was checked and was within regulatory limits. Linens & Hygiene Supplies: Linen supply is in ample supply for residents in care. Hygiene supplies were observed. Emergency Disaster Plan and Mitigation Plan: Available for review. Emergency food and water were present. Food Service: Facility has a supply of 2 day perishables as well as 7 day non-perishables in the main kitchen. LPA observed a posted a menu. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. Smoke Detectors: Smoke detectors are centrally wired and are tested by an outside company. Fire extinguishers are mounted and charged. Carbon monoxide detectors are present and operational. Toxins: LPA observed no unsecured toxins in the facility in the areas toured.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT BRADFORD	FACILITY NUMBER: 306006069
	VISIT DATE: 02/23/2022

NARRATIVE

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Facility Grounds were free of debris or clutter. LPA observed shaded seating in outside patios on the assisted living side as well as the memory care unit. There is a water fountain in the Assisted Living court yard with decorative rocks placed in the water. According to Administrator the fountain is going to be replaced in the near future. Activities: LPA observed an activity schedule posted. Medications, First-Aid Kit & Book: First aid kit observed in the medication room. Medication is stored and locked in medication carts located in the medication room. Resident & Staff Files: Records are secured in locked rooms.

Component III:
Executive Director has extensive knowledge and experience regarding Title 22, Regulations.

The Pre-licensing is complete and there are no deficiencies. The license will be granted upon completion of a final review and approval from the Licensing Program Managers and the Central Applications Bureau.

An exit interview was conducted with Rose Calabrese and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC809 (FAS) - (06/04)

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