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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604455
Report Date: 05/12/2022
Date Signed: 05/12/2022 06:20:44 PM


Document Has Been Signed on 05/12/2022 06:20 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, 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: 78DATE:
05/12/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Angela Scott-Kapiloff, Executive Director, and Jael Wisdom Sanbrano, Evergreen DirectorTIME COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced collateral visit to the facility to conduct interviews. LPA Lopez identified herself, and stated the purpose of the visit with Executive Director, Angela Scott-Kapiloff.

During the visit, LPA Lopez interviewed residents and staff, and requested and obtained relevant documents. No deficiencies were observed during today's visit.

An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director, Angela Scott-Kapiloff, and Evergreen Director, Jael W. Sanbrano, at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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