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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006203
Report Date: 11/13/2024
Date Signed: 11/13/2024 04:33:29 PM

Document Has Been Signed on 11/13/2024 04:33 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 SAN JUAN CAPISTRANOFACILITY NUMBER:
306006203
ADMINISTRATOR/
DIRECTOR:
DAVID ALVARADOFACILITY TYPE:
740
ADDRESS:32200 DEL OBISPO STREETTELEPHONE:
(949) 496-8802
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 120CENSUS: 65DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:David AlvaradoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre, Hanna Gough and Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director/Administrator David Alvarado whose Administrator's Certificate expires January 6, 2026. LPAs and Executive Director toured the facility. The facility is licensed for a capacity of 120 non-ambulatory residents of which 4 can be bed-ridden and a hospice waiver for 15. The facility is a two story building with 90 resident rooms. LPAs observed the kitchen is clean and organized. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPAs observed the refrigerators and freezer are maintained at the required temperatures. LPAs observed a 3 day emergency food and water supply stored in a storage room. LPAs and the Executive Director toured the resident rooms. LPAs observed all resident rooms inspected on the second and first floor had the required furnishings. All resident bathrooms inspected were clean and operational Hot water measured 107.9 to 113.9 degrees Fahrenheit. LPAs observed residents participating in a group activity in the piano room. The facility has 4 stairways. LPAs observed an emergency evacuation chair at each stairway. LPAs observed all fire extinguishers in the facility are fully charged. LPAs observed medication is stored in medication carts in the medication room. LPAs observed an outdoor patio with shaded seating for residents to sit outside. There is a fountain in the outdoor patio. The fountain is empty and has no water. No obstacles or hazards observed inside or outside of the facility. LPAs interviewed staff and residents. LPAs reviewed 6 resident files and medications, no discrepancies observed. LPAs reviewed staff files. No discrepancies observed, all staff files reviewed had the required training and CPR. All staff files reviewed and staff interviewed are background cleared and associated to the facility. The last fire drill was conducted on October 10, 2024. The fire sprinkler system was inspected on July 8, 2024. LPAs inspected the first aid kit. The first aid kit has all the required elements. No deficiencies observed during the visit. LPA consulted with the Executive Director concerning reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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