<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:59:03 PM


Document Has Been Signed on 08/26/2024 04:59 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:IVY PARK AT LAGUNA CREEKFACILITY NUMBER:
347005512
ADMINISTRATOR:MICHELLE SWEARINGENFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 57DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michelle SwearingenTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit.

LPAs Moleski and Williams reviewed 10 resident files (R1-R10) and 10 staff files (S1-S10).

LPAs Moleski and Williams toured the facility with Swearingen and inspected common areas, the kitchen, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPAs Moleski and Williams observed fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPAs Moleski and Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs Moleski and Williams observed locked carts for the storage of medication. LPAs Moleski and Williams observed locked closets for the storage of cleaning solutions.

LPAs Moleski and Williams interviewed four staff members (S11-S12) and four residents (R11-R14).

No deficiencies were cited during this visit. Technical assistance was provided relating to LIC 602s for dementia residents and staff training. An exit interview was conducted and a copy of this report was left with Swearingen.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3