306006402-4-10-2024-22-AS-RQUZ-D47QDT-20240410120513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006402
Report Date: 04/10/2024
Date Signed: 04/10/2024 12:06:11 PM

Document Has Been Signed on 04/10/2024 12:06 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 SEAL BEACH		FACILITY NUMBER:	306006402
ADMINISTRATOR:	TURGEON, JENNIFER		FACILITY TYPE:	740
ADDRESS:	3850 AND 3840 LAMPSON AVE		TELEPHONE:	(562) 594-5788
CITY:	SEAL BEACH	STATE: CA	ZIP CODE:	90740
CAPACITY:	261	CENSUS: 158	DATE:	04/10/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jennifer Turgeon, Executive Director		TIME COMPLETED:	12:08 PM

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Licensing Program Analyst (LPA) Rosie Quiroz conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry by concierge. LPA met with Jennifer Tugeon, Executive Director/Administrator and discussed purpose of the visit.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for capacity of: (261) resident capacity, (51) ambulatory residents, (210) non-ambulatory residents, of which (8) eight residents are able to be bedridden in (A) building only and Hospice waiver for (20) residents was submitted to CCL on July 01, 2023.

Structure:

The facility is a three-story building with a connected walkway on the first floor including A and B building with 155 resident apartment style bedrooms, first floor common spaces are: kitchen, dining room, bistro, bar, library, med room, Beauty salon, movie theater, activity room, two dining-rooms, fitness room, court yard, and seven common restrooms. Second floor common spaces are: Activity room. Third floor common spaces: Relaxation room, Activity room, kitchen, dining-room, TV room, Outdoor court yard. There are 11 laundry units all together throughout all three floors. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There are two courtyards and there is ample seating areas for resident throughout both courtyards. There is a front patio with seating for residents in front of the facility on both A and B buildings.

Signal system:

Each apartment has a call button/pull cord to request assistance and residents also utilize pendant alert system to request assistance.

CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT SEAL BEACH	FACILITY NUMBER: 306006402
	VISIT DATE: 04/10/2024

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Air/Heating:Central air/heating system installed with a central panel to control entire building. Today’s facility temperature was recorded to be 72degrees Fahrenheit.

Bedrooms Residents: Bedrooms are apartment style that will be private or shared.

Bedrooms Staff:There is no live in staff and there is a designated staff lounge.

Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower/tub. There are seven common restrooms on the first floor of the building and each apartment has its own bathroom.

Linens & Hygiene Supplies:Facility has an adequate supply of linens in storage unit.

Emergency Phone Numbers, Exit Plan & Menu:Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. All day menu with substitute meals provided.

Food Service: Adequate supply of seven day non-perishable and two day perishables are stored in the kitchen with surplus good stored in shed area out in the back parking lot behind the kitchen.

Smoke Detectors: Smoke detectors, sprinklers and carbon monoxide alert systems are tested and maintained by an outside vendor. Fire extinguishers mounted throughout the facility charged with a date of October 03, 2023.

Appliances:

Residents’ apartments have small kitchen, Building B apartments have full kitchens, refrigerator, microwave, and small sink. Facility main kitchen on the first floor is equipped with ovens/ranges/microwaves, prep counters, refrigeration, freezer, grill, steam tables. Building B apartments have individual washer and dryer in each apartment. Building A has a common laundry area with operational and functional washers and dryers and a commercial washer/dryer area with functional and operational washers and dryers.

Toxins:

All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents and stored in housekeeping and maintenance supply closets. CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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 SEAL BEACH	FACILITY NUMBER: 306006402
	VISIT DATE: 04/10/2024

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Water Temperature:Tested and recorded the water temperatures measuring 106.0 – 113.4 degrees Fahrenheit in resident apartments and common bathrooms in all three floors of A and B buildings.

Pool:There is no pool or any body of water in this facility.

Medications, First-Aid Kit & Book: Medication, first aid and book are stored in med room inaccessible to residents. First aid kits are also located in med carts and throughout the facility in common spaces.

Resident & Staff Files: Records will be kept stored in file cabinet located on the first floor in the business office.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation.

Fire clearance: On October 3, 2023 Fire department granted the following: (261) resident capacity, (51) ambulatory residents, (210) non-ambulatory residents, of which (8) eight residents are able to be bedridden in (A) building only.

Component III: Component III was completed with ED Turgeon during today's pre-licensing inspection.

The Facility appears to be ready for licensure in the areas inspected. ED Turgeon was informed today that the facility is ready for licensure pending final approval processed by the Centralized Applications Bureau (CAB) in Sacramento.

An exit interview was conducted with ED Jennifer Turgeon and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC809 (FAS) - (06/04)

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