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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002954
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:48:36 PM


Document Has Been Signed on 01/10/2024 03:48 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 119DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with Administrator Chad Rogers during today's inspection. Currently there are 112 residents of which 7 residents are receiving hospice care.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 7 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA measured the hot water to be 119 degrees Fahrenheit. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 10 resident files and 10 staff files. LPA reviewed 3 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance.

No deficiencies observed during inspection.

Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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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