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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002954
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:23:10 PM


Document Has Been Signed on 08/13/2024 03:23 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:CHAD ROGERSFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:140CENSUS: 120DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Chad Rogers, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi and Graham Gunby arrived unannounced to conduct a case- management. LPA met with Administrator Chad Rogers during today's inspection.

LPA arrived to discuss two separate incident reports received from the facility. LPA interviewed administrator concerning incident and reviewed documentation. It appears facility followed proper protocol and regulation on each incident that occurred.

At this time, no deficiencies cited during today's inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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