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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800448
Report Date: 12/11/2023
Date Signed: 12/11/2023 05:09:39 PM


Document Has Been Signed on 12/11/2023 05:09 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:IVY PARK AT ALTA LOMAFACILITY NUMBER:
361800448
ADMINISTRATOR:ENDERT, ROGERFACILITY TYPE:
740
ADDRESS:9519 BASELINE RDTELEPHONE:
(949) 744-5200
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:77CENSUS: 55DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jennifer Sanchez. AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Jennifer Sanchez, administrator, and was granted entry to the facility. The facility is a 77 capacity Residential Care Facility for the Elderly (RCFE) with a census of 55 and a hospice waiver of 12, as well as 25 bedridden. The inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected eleven (11) client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire Marshal records were obtained for cleared and operational functions of such detector. Fire drills are being conducted per regulation. Water temperature measured on average of 116 degrees at today's inspection. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. Medication room was reviewed and staff interviewed and operating within Title 22 regulations.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: IVY PARK AT ALTA LOMA
FACILITY NUMBER: 361800448
VISIT DATE: 12/11/2023
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Freezers and refrigerator are at the appropriate temperatures. Perishables are rotated to assure food does not expire.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Client and Staff Review: Eleven (11) client files were review and have the appropriate documentation including appraisals, needs and services plans and admission's agreement. Five (5) staff files were reviewed and have the appropriate documentation including fingerprint clearance, TB clearance and appropriate training.


Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Ms Sanchez.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2