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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701234
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:56:15 PM


Document Has Been Signed on 07/13/2023 04:56 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:IVY RIDGE ASSISTED LIVINGFACILITY NUMBER:
342701234
ADMINISTRATOR:KITNIKONE, SUNNIEFACILITY TYPE:
740
ADDRESS:2030 23RD STTELEPHONE:
(916) 600-3309
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 27DATE:
07/13/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lezel BelloTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a post-licensing inspection on 7/13/2023. LPA met with Assistant Administrator Lezel Bello and explained the purpose of the visit. Lezel will assist LPA with today’s inspection. There are 27 residents in care currently.

LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, medication room and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature was measured at 111.9*F which was within the required range of 105-120*F. The temperature inside the facility was observed to be at 75*F which was within the required range of 68-85*F.

LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.

LPA reviewed (3) resident files and (3) staff files, including criminal record clearances. LPA confirmed all residents’ files have required records. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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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