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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604455
Report Date: 04/11/2022
Date Signed: 04/12/2022 08:54:24 AM


Document Has Been Signed on 04/12/2022 08:54 AM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:IVY PARK AT OTAY RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR:KAPLIOFF, ANGELAFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:137CENSUS: 79DATE:
04/11/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator - Angela Scott-Kapiloff TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Marisela Garcia- Centeno made an unannounced collateral visit to the facility to conduct an interview with Resident #1 (R1). LPA met with Administrator, Angela Scott-Kapiloff and we discussed the reason for the visit. The Confidential Names Form LIC 811 was provided in order to identify R1

During today's visit LPA conducted an interview with R1.

No deficiencies were observed during the visit. An exit interview was conducted with Administrator, Scott-Kapiloff to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided to via email. An email receipt confirms the acknowledgement of these documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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