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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006435
Report Date: 07/23/2024
Date Signed: 07/23/2024 07:25:41 AM


Document Has Been Signed on 07/23/2024 07:25 AM - 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 TUSTINFACILITY NUMBER:
306006435
ADMINISTRATOR:BROADHURST, BRENTFACILITY TYPE:
740
ADDRESS:12291 S. NEWPORT AVE.TELEPHONE:
(714) 544-5959
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:70CENSUS: 48DATE:
07/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
06:53 AM
MET WITH:Sandra Acosta-Louer- Executive DirectorTIME COMPLETED:
07:45 AM
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Licensing Program Analyst (LPA) Jessica Cho conducted an announced subsequent Pre-Licensing continuation visit. LPA Cho was allowed entry into the facility and met with Executive Director Sandra Acosta-Louer. The purpose of today's visit was to follow-up on the issues that were present during the initial Pre-Licensing visit on July 18, 2024 The following issues were observed and required correction:
  • To ensure the water temperature in the resident bathrooms are within the range of 105-120 degrees Fahrenheit.
  • To post a copy of the admission agreement, licensing report(s), and resident council meeting notes or maintain a notice of their availability for the public upon request.
  • To complete and post Page 2 of the Emergency Disaster Plan (LIC610E) (3/19) that was missing.
  • To hang the Administrator's Certificate.

Component III is waived due to the applicant having other licensed facilities and completing Component III previously.

On today's visit the aforementioned items have been addressed and corrected. The aforementioned items reviewed during this visit are in compliance. The Pre-Licensing is now complete. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted, and a copy of this report was provided at the time of this visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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