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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604269
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:43:47 PM

Document Has Been Signed on 01/17/2025 03:43 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:IVY PARK AT ESCONDIDOFACILITY NUMBER:
374604269
ADMINISTRATOR/
DIRECTOR:
JOHN BRENNANFACILITY TYPE:
740
ADDRESS:930 MONTICELLO DRIVETELEPHONE:
(760) 747-4888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 123TOTAL ENROLLED CHILDREN: 0CENSUS: 80DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Administrator Sam DeGuzmanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Administrator, Samuel De Guzman. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

The facility is a two story structure consists of memory care residents on the first floor and assisted living residents on the second floor. The facility has a main kitchen on the first floor, multiple dinning areas, activity rooms such as a library, gym, hair salon, and movie theaters, a patio and yard with sufficient seating and space for activities. LPA inspected 10 resident rooms and observed grab bars for each toilet, bathtub and shower used by residents. Water temperature was tested in the rooms observed and measured to be within regulation. Resident showers have non-skid texture floor. The rooms were kept clean and free of any odors. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. There are no firearms at this home and no bodies of water observed.

LPA began review of client records. ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete.

LPA began review of employee records- Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 08/28/2026. LPA observed personnel records to be available.

Jazmond D HarrisTELEPHONE: (951) 529-2439
Armando PerezTELEPHONE: (951) 248-2222
DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: IVY PARK AT ESCONDIDO
FACILITY NUMBER: 374604269
VISIT DATE: 01/17/2025
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LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

Medications are centrally stored. There are two locked rooms allocated for medication storage. One room is located on the first floor and the second is located on the second floor. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.



LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Administrator stated the smoke detectors and carbon monoxide detectors are serviced quarterly. LPA observed fire extinguishers were in compliance and last serviced March 4, 2024. The facility is conducting emergency disaster/fire drills monthly; last done on 01/13/2025.

Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809 report was reviewed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 529-2439
LICENSING EVALUATOR NAME: Armando PerezTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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