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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604455
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:56:31 PM


Document Has Been Signed on 04/18/2024 02:56 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:IVY PARK AT OTAY RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR:CALAIS ANGUIANOFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:137CENSUS: 107DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Silvia GarciaTIME COMPLETED:
01:29 PM
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Business Office Director Silvia Garcia, to discuss the purpose of the visit. 

Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who suffered a fall and hit their head.

LPA interviewed staff and obtained facility records. R1 remained hospitalized at the time of the visit. No deficiencies were cited or observed on this date. 

An exit interview was conducted with Silvia Garcia, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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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