306006451-7-17-2024-22-AS-KSGH-D79VCM-20240717161922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006451
Report Date: 07/17/2024
Date Signed: 07/17/2024 04:22:04 PM

Document Has Been Signed on 07/17/2024 04:22 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 LA PALMA		FACILITY NUMBER:	306006451
ADMINISTRATOR:	MUNOZ, JENNIFER		FACILITY TYPE:	740
ADDRESS:	5321 LA PALMA AVENUE		TELEPHONE:	(724) 739-8111
CITY:	LA PALMA	STATE: CA	ZIP CODE:	90623
CAPACITY:	80	CENSUS: 69	DATE:	07/17/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jennifer Munoz, Executive Director		TIME COMPLETED:	04:30 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility to follow up on the initial pre-licensing visit conducted by LPA Celine De Perio on May 17, 2024. LPA was greeted and granted entry by the facility's front desk staff after introducing himself and stating the reason for the visit. Executive Director Jennifer Munoz was present to assist with the visit. The licensing update is related to a change of ownership with residents in care present. LPA accompanied by Executive Director conducted a tour of the facility's indoor and outdoor physical plant. The facility is a two-level building with a total of 59 units and a total capacity of 80 residents. On the day of the visit, there were 69 residents admitted to the facility, 22 of which living in the facility's memory care unit. Occupied living units were toured on both the ground level and the upper level and were verified to include all necessary items of furniture. Bathrooms are equipped with rails and showers are observed to be including anti-slip material. Water temperatures were measured on both levels to be within the required range. Required postings are verified to be present. There is adequate outdoor space with shade for the residents both in Assisted Living as well as in Memory Care. The facility is verified to be clean and in good repair. Facility residents observed appear to be relaxed and well taken care of. The facility is also equipped with a functional call system with pull cords located in each bedroom and bathroom as well as additional individual pendants available by personal choice. The facility has a valid current fire clearance for 76 non-ambulatory and 4 bedridden residents. Carbon monoxide detectors and sprinklers are wired. Proof of operation being verified was provided during the visit. Evacuation chairs are present in each of the two evacuation stairwells. The memory care outdoor area is equipped with delayed egress doors leading out into the yard and outside of the facility. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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 LA PALMA	FACILITY NUMBER: 306006451
	VISIT DATE: 07/17/2024

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CONTINUED FROM FORM LIC809

LPA reviewed the facility's fire clearance issued by the Orange County Fire Authority on November 30, 2023 as well as the facility's Emergency and Disaster Plan and Infection Control document. LPA observed that the fire clearance does not include an explicit mention of the delayed egress in use to exit the memory care unit into the secure courtyard as well as to exit the courtyard onto the facility's parking lot. LPA provided a consultation on the requirement from Title 22 of the California Code of Regulations Section 87705(k)(2) regarding the Care of Persons with Dementia indicating that :"The licensee shall ensure that the fire clearance includes approval of delayed egress devices". Licensee will request an update of the fire clearance to the Fire Marshall in order for licensing to be approved.

Proof of liability insurance was provided during the visit. LPA requested and obtained the list of staff members as well as the current resident roster. Five staff records and five resident records were randomly selected and reviewed to include all necessary components.

An exit interview was conducted and a copy of this report along with two Technical Assistance Advisory Notes were provided to a facility representative. This report was amended to add the expected corrections required ahead of the new license being issued. A signed copy will be obtained and kept in the facility file.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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