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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001903
Report Date: 12/20/2022
Date Signed: 12/20/2022 04:23:13 PM


Document Has Been Signed on 12/20/2022 04:23 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:IVY RIDGE ASSISTED LIVINGFACILITY NUMBER:
347001903
ADMINISTRATOR:TRINH, HONGFACILITY TYPE:
740
ADDRESS:2030 23RD STREETTELEPHONE:
(916) 455-8849
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 29DATE:
12/20/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Hong TrinhTIME COMPLETED:
04:35 PM
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On 12/20/22, Licensing Program Analyst (LPA) Tung Truong conducted a plan of correction (POC) visit in relation to citations issued during a case management on 12/15/22. LPA met with Administrator Hong Trinh and explained the purpose of the visit.

*Deficiency cited under Title 22 Regulation 87405(a) - Cleared. Licensee complied with the terms of the POC by POC due date.


*Deficiency cited under Title 22 Regulation 87465(a)(1) - Cleared. Licensee complied with the terms of the POC by POC due date.
*Deficiency cited under Title 22 Regulation 87465(h)(2) - Cleared. Licensee complied with the terms of the POC by POC due date.
*Deficiency cited under Health and Safety Code 1569.191(a)(1) - Cleared. Licensee complied with the terms of the POC by POC due date.
*Deficiency cited under Health and Safety Code 1569.191(b) - Cleared. Licensee complied with the terms of the POC by POC due date.
*Deficiency cited under Title 22 Regulation 87465(a)(1) - Cleared. Licensee complied with the terms of the POC by POC due date.
*Deficiency cited under Title 22 Regulation 87303(a) - Cleared. Licensee complied with the terms of the POC by POC due date.
*Deficiency cited under Health and Safety Code 1569.269(a)(6) - Cleared. Licensee complied with the terms of the POC by POC due date.
*Deficiency cited under Title 22 Regulation 87705(k)(4) - Cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.
Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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