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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002954
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:26:22 PM


Document Has Been Signed on 12/15/2022 01:26 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:IVY PARK OF ROSEVILLEFACILITY NUMBER:
315002954
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:140CENSUS: 102DATE:
12/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jessica Pryor TIME COMPLETED:
01:45 PM
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On 12/15/2022, Licensing Program Analyst (LPA) Talwinder Bains met with administrator , Jessica Pryor, to conduct an Pre- Licensing visit. LPA followed current Covid precautions- self screened, hand sanitized and surgical mask worn. This application is a change in ownership (CHOW) . This address is currently licensed as SIERRA POINTE, Facility # 312700263. Administrator holds a current administrator certificate
(# 6031064740 with expiration date 07/16/2024).
The facility currently has 102 residents during today's inspection.

LPA toured the facility with administrator. LPA toured 2 sample residents bedrooms and they were properly furnished and maintained. LPA toured common bathrooms and observed to be clean and sanitary. The food supply is within compliance, 2 days of perishable and 7 days’ worth of non-perishable food items. Smoke detectors are operational. There are carbon monoxide detectors which are functioning. The Fire extinguisher was charged, serviced and functional. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. The disaster drill is current.

Component III was waived as the current administrator has been administrator for other RCFEs licensed by CCLD . LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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