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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006463
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:40:38 AM

Document Has Been Signed on 11/07/2024 11:40 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 FULLERTONFACILITY NUMBER:
306006463
ADMINISTRATOR/
DIRECTOR:		HALE, CHRISTINAFACILITY TYPE:
740
ADDRESS:2226 NORTH EUCLID STREETTELEPHONE:
(714) 738-3656
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 85CENSUS: 56DATE:
11/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:Cherie Harris-Business Office Director, Christina Hale-AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Business Office Director (BOD) Cherie Harris. Administrator (AD) Christina Hale arrived shortly after.

An application for Change of Ownership (CHOW) to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on November 13, 2023. The facility is to have a capacity of 85, of which 77 can be nonambulatory and eight bedridden. Facility phone number 714-738-3656. LPA observed the following.



Structure:
The facility is a two-story structure and consists of the following: 65 resident bedrooms, six offices, living room area, dining room, private dining room, two activity studios, salon, theater room, kitchen, bistro, lounge parking garage, and outdoor seating area. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is an enclosed courtyard and a sensory room in the memory care unit. LPA did not observe any obstacles or hazards in the courtyard and/or hallways.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets.

Signal system
Signal system was tested and observed to be operable.

CONTINUED ON LIC9099-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 FULLERTON
FACILITY NUMBER: 306006463
VISIT DATE: 11/07/2024
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Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the various storage rooms.

Medications, First-Aid Kit & Book:
Medication is stored in a locked staff office in a locked medicine cart. First aid kit is stored in the medication room. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in a staff office.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
A fire extinguisher is located in every hallway and in the kitchen of the facility. Fire extinguishers were fully charged with service tags dated October 17, 2024.

Reading Material, Games, Equipment & Materials:
The facility has reading books, arts and crafts supplies, board games, puzzles, and other recreational materials for resident use stored in the activity room.

Bedrooms Staff:
There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 107.6 and 112.2 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the laundry rooms.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 FULLERTON
FACILITY NUMBER: 306006463
VISIT DATE: 11/07/2024
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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review, an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was also posted and available.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors:
Carbon monoxide detectors tested operational. Fire alarm was tested on April 30, 2024 by Johnson Controls.

Appliances:
Gas burner stove, refrigerators, walk-in freezer, microwave, washers, and dryers were inspected and observed to be operational.

Fire clearance:


Fire Clearance approved by a fire inspector of Fullerton Fire Department on May 16, 2024. Special conditions noted, "No restraints. No smoking in rooms utilizing air induced mattresses. Temporally bedridden provide the Fullerton Fire Department with notification within 48 hours of resident's admission or retention in the facility."

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

LPA advised Applicant to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for inquiries and to submit incident reports.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB (Centralized Application Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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