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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001903
Report Date: 01/12/2022
Date Signed: 01/12/2022 04:46:10 PM

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 RETIREMENT HOMEFACILITY NUMBER:
347001903
ADMINISTRATOR:JOSHIKA PRASADFACILITY TYPE:
740
ADDRESS:2030 23RD STREETTELEPHONE:
(916) 455-8849
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:36CENSUS: 20DATE:
01/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Jennifer HobbsTIME COMPLETED:
05:00 PM
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On 1/12/2022 at 3:50 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a proof of correction (POC) visit in regard to deficiencies cited on 1/04/2022. LPA met with Office Manager Jennifer Hobbs and explained the purpose of today’s visit.

LPA observed water temperature in the kitchen is 109 degrees Fahrenheit, sink in room 12 is 107.6 degrees Fahrenheit and bathroom is 112.0 degrees Fahrenheit.



*Deficiency cited under Title 22 Regulation 87303(e)(2) – Cleared. Proof of correction was submitted on 1/05/2022. 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 was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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